1205174497 NPI number — TOWN TOTAL HEALTH, LLC

Table of content: (NPI 1205174497)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205174497 NPI number — TOWN TOTAL HEALTH, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TOWN TOTAL HEALTH, LLC
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:
6
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:
1205174497
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2929 WALKER AVE. NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49544-6402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-791-2829
Provider Business Mailing Address Fax Number:
616-735-8532

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 CROSSWAYS PARK DRIVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
WOODBURY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11797
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-249-7400
Provider Business Practice Location Address Fax Number:
516-249-7400
Provider Enumeration Date:
01/22/2013

Additional Information

Authorized Official

Authorized Official Last Name:
VALENTI
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
631-386-1204

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  031852 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2140160 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2314881 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 03563164 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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