1275748923 NPI number — VCMY II CORPORATION

Table of content: (NPI 1275748923)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275748923 NPI number — VCMY II CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VCMY II CORPORATION
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:
1275748923
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1294
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHELBYVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40066-1294
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-647-3474
Provider Business Mailing Address Fax Number:
502-647-9572

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
163 ALPINE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBYVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40065-8878
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-647-3474
Provider Business Practice Location Address Fax Number:
502-647-9572
Provider Enumeration Date:
05/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MYATT
Authorized Official First Name:
RONNIE
Authorized Official Middle Name:
JOE
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
502-647-3474

Provider Taxonomy Codes

  • Taxonomy code: 320600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 33000688 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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