1225258635 NPI number — MARLBORO CLINIC CORP

Table of content: (NPI 1225258635)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225258635 NPI number — MARLBORO CLINIC CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARLBORO CLINIC CORP
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:
1225258635
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7100 COMMERCE WAY
Provider Second Line Business Mailing Address:
SUITE 180
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-2829
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-465-7000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1076 MARLBORO WAY
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
BENNETTSVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29512-2495
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-454-2294
Provider Business Practice Location Address Fax Number:
843-454-2342
Provider Enumeration Date:
04/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BREWER
Authorized Official First Name:
DEBBIE
Authorized Official Middle Name:
T
Authorized Official Title or Position:
PROVIDER ENROLLMENT
Authorized Official Telephone Number:
615-465-7626

Provider Taxonomy Codes

  • Taxonomy code: 207VX0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GP3861 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com