1336683101 NPI number — GL VIRGINIA BLUE RIDGE, LLC

Table of content: (NPI 1336683101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336683101 NPI number — GL VIRGINIA BLUE RIDGE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GL VIRGINIA BLUE RIDGE, 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:
GALAX HEALTH AND REHAB
Provider Other Organization Name Type Code:
3
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:
1336683101
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
836 GLENDALE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GALAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24333-2490
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-236-9991
Provider Business Mailing Address Fax Number:
276-236-5563

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
836 GLENDALE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GALAX
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24333-2490
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-236-9991
Provider Business Practice Location Address Fax Number:
276-236-5563
Provider Enumeration Date:
12/13/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RUBENSTEIN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT AND CEO
Authorized Official Telephone Number:
404-786-8528

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , 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)