1457769762 NPI number — JH ORG 07302014

Table of content: (NPI 1457769762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457769762 NPI number — JH ORG 07302014

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JH ORG 07302014
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:
SMOKE 04/04
Provider Other Organization Name Type Code:
5
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:
1457769762
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
08/16/2020
NPI Reactivation Date:
08/16/2020

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5225 23RD AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARGO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58104-7927
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
123-456-7890
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6801 KENNEDY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARRENTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20187-3995
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
324-324-3434
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/30/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ORG-A
Authorized Official First Name:
TEST
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMIN
Authorized Official Telephone Number:
555-111-2222

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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