1376874461 NPI number — W & R GEYSER RD, LLC

Table of content: (NPI 1376874461)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376874461 NPI number — W & R GEYSER RD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
W & R GEYSER RD, 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:
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:
1376874461
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
424 GEYSER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALLSTON SPA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12020-3021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-885-1095
Provider Business Mailing Address Fax Number:
518-885-1137

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
424 GEYSER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALLSTON SPA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12020-3021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-885-1095
Provider Business Practice Location Address Fax Number:
518-885-1137
Provider Enumeration Date:
01/29/2010

Additional Information

Authorized Official

Authorized Official Last Name:
CHAUVIN
Authorized Official First Name:
NICHOLAS
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
518-885-1095

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  32884 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00527913 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com