1306838966 NPI number — WINCHESTER-WAYNE TOWNSHIP LIFE SQUAD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306838966 NPI number — WINCHESTER-WAYNE TOWNSHIP LIFE SQUAD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WINCHESTER-WAYNE TOWNSHIP LIFE SQUAD
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:
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:
1306838966
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4750 HEMPSTEAD STATION DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KETTERING
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45429-5164
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-875-0136
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 WASHINGTON ST
Provider Second Line Business Practice Location Address:
BOX 215
Provider Business Practice Location Address City Name:
WINCHESTER
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45697
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-695-0447
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CHANEY
Authorized Official First Name:
JOSHUA
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF
Authorized Official Telephone Number:
937-695-0447

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000010000 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0457376 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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