1245228444 NPI number — REVERA (DELAWARE) LLC

Table of content: (NPI 1245228444)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245228444 NPI number — REVERA (DELAWARE) LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REVERA (DELAWARE) 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:
1245228444
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
538 PRESTON AVE
Provider Second Line Business Mailing Address:
SUITE 270
Provider Business Mailing Address City Name:
MERIDEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06450-4851
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-608-6100
Provider Business Mailing Address Fax Number:
203-639-3574

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 N. MEDCALF
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTESANO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98563-1318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-249-2273
Provider Business Practice Location Address Fax Number:
360-249-2363
Provider Enumeration Date:
10/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SCILLIA
Authorized Official First Name:
CAROLE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
LLC MANAGER
Authorized Official Telephone Number:
203-608-6100

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  050005680 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 1369 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4113692 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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