1578639654 NPI number — INDIAN RIVER RESIDENTIAL CARE COMMUNITY

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 1578639654 NPI number — INDIAN RIVER RESIDENTIAL CARE COMMUNITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIAN RIVER RESIDENTIAL CARE COMMUNITY
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:
1578639654
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:
PO BOX 1487
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KERNERSVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27285-1487
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-595-1075
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1012 JUSTIS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHESAPEAKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23325-2516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-523-4659
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PIERCE
Authorized Official First Name:
GUY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
336-595-1075

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X , 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: 5002281 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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