1184893166 NPI number — THE HERITAGE OF RICHLANDS

Table of content: JAMEE LEANN LAO VASQUEZ CD (NPI 1891505871)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184893166 NPI number — THE HERITAGE OF RICHLANDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE HERITAGE OF RICHLANDS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184893166
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 878
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK RIDGE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27310-0878
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-643-0555
Provider Business Mailing Address Fax Number:
336-643-0553

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
148 COX AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHLANDS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28574-6163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-324-1121
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/25/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PIERCE
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
VANN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
336-643-0555

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  HAL067016 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 311ZA0620X , with the licence number: HAL-067-016 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7805975 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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