1578987517 NPI number — STILL WATERS LIFE CENTER, LLC

Table of content: (NPI 1578987517)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578987517 NPI number — STILL WATERS LIFE CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STILL WATERS LIFE CENTER, LLC
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:
1578987517
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 347134
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PARMA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44134-7134
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-829-1788
Provider Business Mailing Address Fax Number:
440-888-1970

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10277 VALLEY VIEW RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MACEDONIA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44056-1740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-829-1788
Provider Business Practice Location Address Fax Number:
440-888-1970
Provider Enumeration Date:
02/11/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CHROSNIAK
Authorized Official First Name:
CONNIE
Authorized Official Middle Name:
V
Authorized Official Title or Position:
EXECUTIVE DIRECTOR/OWNER
Authorized Official Telephone Number:
440-829-1788

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  C.0090570 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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