1255407680 NPI number — ECEP II PA

Table of content: (NPI 1255407680)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255407680 NPI number — ECEP II PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ECEP II PA
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:
1255407680
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4402 SHIPYARD BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28403-6161
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-202-3363
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
507 E FREMONT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURGAW
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28425-5131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-237-3378
Provider Business Practice Location Address Fax Number:
843-237-5073
Provider Enumeration Date:
11/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KEY
Authorized Official First Name:
DALE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
910-202-3363

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: QPB855 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01456 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5905762 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7901456 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: CI9263 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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