1396496063 NPI number — BLAND COUNTY MEDICAL CLINIC, INC.

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 1396496063 NPI number — BLAND COUNTY MEDICAL CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLAND COUNTY MEDICAL CLINIC, INC.
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:
6
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:
1396496063
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12301 GRAPEFIELD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BASTIAN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24314-4547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-688-4331
Provider Business Mailing Address Fax Number:
276-688-4336

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8494 S SCENIC HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLAND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24315-5255
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-688-0500
Provider Business Practice Location Address Fax Number:
276-688-4336
Provider Enumeration Date:
01/14/2022

Additional Information

Authorized Official

Authorized Official Last Name:
GOODMAN
Authorized Official First Name:
GINA
Authorized Official Middle Name:
GAIL
Authorized Official Title or Position:
CREDENTIALING & ENROLLMENT/OUTREACH
Authorized Official Telephone Number:
276-688-4331

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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