1225075294 NPI number — MARY IMMACULATE NURSING CENTER LLC

Table of content: (NPI 1225075294)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225075294 NPI number — MARY IMMACULATE NURSING CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARY IMMACULATE NURSING CENTER 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:
1225075294
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8580 MAGELLAN PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23227-1149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-627-5573
Provider Business Mailing Address Fax Number:
866-449-0896

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4 RIDGEWOOD PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWPORT NEWS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23602-4415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-886-6500
Provider Business Practice Location Address Fax Number:
757-886-6539
Provider Enumeration Date:
05/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RALSTON
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
Authorized Official Title or Position:
SYSTEM DIRECTOR
Authorized Official Telephone Number:
419-996-5119

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH2695 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4952049 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 227691 . This is a "ANTHEM PROVIDER NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 004952049 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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