1619120904 NPI number — BRIDGES AT FARMVILLE

Table of content: (NPI 1619120904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619120904 NPI number — BRIDGES AT FARMVILLE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIDGES AT FARMVILLE
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:
1619120904
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 2496
Provider Second Line Business Mailing Address:
BRIDGES AT FARMVILLE C/O TERESA TATLOCK
Provider Business Mailing Address City Name:
LYNCHBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24505-2828
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-947-4818
Provider Business Mailing Address Fax Number:
434-237-5412

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
646 PERSIMMON TREE FORK
Provider Second Line Business Practice Location Address:
BRIDGES AT FARMVILLE ROAD
Provider Business Practice Location Address City Name:
FARMVILLE CITY
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23901-4349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-947-5700
Provider Business Practice Location Address Fax Number:
434-947-4565
Provider Enumeration Date:
10/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GORMAN
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
H.
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
434-947-5700

Provider Taxonomy Codes

  • Taxonomy code: 323P00000X , with the licence number:  052-14-003 , 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)





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