1205394558 NPI number — FLINT RIDGE HEALTHCARE LLC

Table of content: (NPI 1205394558)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205394558 NPI number — FLINT RIDGE HEALTHCARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLINT RIDGE HEALTHCARE 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:
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:
1205394558
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 AMERICA AVE UNIT 304
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKEWOOD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08701-4582
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-487-7479
Provider Business Mailing Address Fax Number:
732-276-5556

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1450 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43055-1825
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-348-1300
Provider Business Practice Location Address Fax Number:
740-344-3091
Provider Enumeration Date:
03/06/2019

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
HAYLEY
Authorized Official Middle Name:
B
Authorized Official Title or Position:
ATTORNEY
Authorized Official Telephone Number:
216-706-3936

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1489N . This is a "LICENSE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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