1306941505 NPI number — CHILDREN'S CLINIC, LTD

Table of content: (NPI 1306941505)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306941505 NPI number — CHILDREN'S CLINIC, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILDREN'S CLINIC, LTD
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:
1306941505
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
321 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWPORT NEWS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23601-3814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-595-0358
Provider Business Mailing Address Fax Number:
757-595-6745

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
321 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWPORT NEWS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23601-3814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-595-0358
Provider Business Practice Location Address Fax Number:
757-595-6745
Provider Enumeration Date:
09/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLALOCK
Authorized Official First Name:
JULIAN
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
757-595-0358

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  0101035213 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1316942550 . This is a "NPI NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1619972833 . This is a "NPI NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1699770826 . This is a "NPI NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1104821339 . This is a "NPI NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1639174436 . This is a "NPI NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 006703828 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 006716962 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 006729932 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 006769187 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 006797059 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1467457697 . This is a "NPI NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 010043859 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1891790028 . This is a "NPI NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1972508778 . This is a "NPI NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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