1417955733 NPI number — DISCOVERY HOUSE UTAH

Table of content: (NPI 1417955733)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417955733 NPI number — DISCOVERY HOUSE UTAH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DISCOVERY HOUSE UTAH
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:
1417955733
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
66 PAVILION AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROVIDENCE
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02905-1522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-780-2300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
88 W WARWICK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST WARWICK
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02893-3871
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-821-8866
Provider Business Practice Location Address Fax Number:
401-821-1319
Provider Enumeration Date:
07/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MORRIS
Authorized Official First Name:
PETER
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT OF FINANCE
Authorized Official Telephone Number:
401-780-2300

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , with the licence number:  608.3 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1029400 . This is a "BEACON HEALTH STRATEGIES" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 8481061 . This is a "UNITED RITECARE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 410268 . This is a "BLUECHIP RITECARE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: DH42856 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8410032 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".




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