1508856063 NPI number — POLASKI COUNTY BOARD OF SUPERVISORS

Table of content: (NPI 1508856063)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508856063 NPI number — POLASKI COUNTY BOARD OF SUPERVISORS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POLASKI COUNTY BOARD OF SUPERVISORS
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:
1508856063
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 290184
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WETHERSFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06129-0184
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-257-9201
Provider Business Mailing Address Fax Number:
860-721-6362

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6580 VALLEY CENTER DR
Provider Second Line Business Practice Location Address:
STE 118
Provider Business Practice Location Address City Name:
FAIRLAWN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24141-5669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-633-6743
Provider Business Practice Location Address Fax Number:
540-633-6745
Provider Enumeration Date:
10/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GENTILE
Authorized Official First Name:
MARY
Authorized Official Middle Name:
T
Authorized Official Title or Position:
AUTHORIZED AGENT
Authorized Official Telephone Number:
860-257-9201

Provider Taxonomy Codes

  • Taxonomy code: 341600000X , with the licence number:  856 , 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)

  • Identifier: 009011293 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 590009886 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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