1538101951 NPI number — INDEPENDENCE FAMILY CARE CENTER, PC

Table of content: (NPI 1538101951)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538101951 NPI number — INDEPENDENCE FAMILY CARE CENTER, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDEPENDENCE FAMILY CARE CENTER, PC
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:
1538101951
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
217 S INDEPENDENCE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDEPENDENCE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24348-2802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-773-2111
Provider Business Mailing Address Fax Number:
273-773-2942

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
217 S INDEPENDENCE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24348-2802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-773-2111
Provider Business Practice Location Address Fax Number:
273-773-2942
Provider Enumeration Date:
06/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LOVELACE
Authorized Official First Name:
NANCE
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
276-773-2111

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , 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: 010084326 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010134129 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: S66686 . This is a "REYNOLDS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 010094640 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 143862 . This is a "BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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