1255684858 NPI number — JUSTIN'S BLACK TEA AND BREAD, A TEA ROOM LLC

Table of content: (NPI 1255684858)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255684858 NPI number — JUSTIN'S BLACK TEA AND BREAD, A TEA ROOM LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JUSTIN'S BLACK TEA AND BREAD, A TEA ROOM 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:
1255684858
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 PROVIDENCE ST
Provider Second Line Business Mailing Address:
STE 203
Provider Business Mailing Address City Name:
STAFFORD
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22554-8300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-589-5432
Provider Business Mailing Address Fax Number:
540-657-9732

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 PROVIDENCE ST
Provider Second Line Business Practice Location Address:
STE 203
Provider Business Practice Location Address City Name:
STAFFORD
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22554-8300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-589-5432
Provider Business Practice Location Address Fax Number:
540-657-9732
Provider Enumeration Date:
10/19/2012

Additional Information

Authorized Official

Authorized Official Last Name:
PROCTOR
Authorized Official First Name:
JUSTIN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT CEO
Authorized Official Telephone Number:
703-589-5432

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com