1306811914 NPI number — TERRENCE L VANDIVER

Table of content: TERRENCE L VANDIVER (NPI 1306811914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306811914 NPI number — TERRENCE L VANDIVER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDIVER
Provider First Name:
TERRENCE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1306811914
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1631 GORDON HWY
Provider Second Line Business Mailing Address:
#22
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30906-2292
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-790-9302
Provider Business Mailing Address Fax Number:
706-790-9303

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1631 GORDON HWY
Provider Second Line Business Practice Location Address:
#22
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30906-2292
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-790-9302
Provider Business Practice Location Address Fax Number:
706-790-9303
Provider Enumeration Date:
02/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DN012433 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: 3827 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: ZX3827 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 747629278A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9180178 . This is a "DENTAQUEST" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 2670243 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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