1629106430 NPI number — CAPITAL BRAIN CENTER, PA

Table of content: (NPI 1629106430)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629106430 NPI number — CAPITAL BRAIN CENTER, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAPITAL BRAIN CENTER, PA
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:
1629106430
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 9426
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29290-9426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-551-2900
Provider Business Mailing Address Fax Number:
803-551-2979

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2800 BUSH RIVER RD STE 5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29210-5662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-551-2900
Provider Business Practice Location Address Fax Number:
803-551-2979
Provider Enumeration Date:
03/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RAO
Authorized Official First Name:
SUBBA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
803-551-2900

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  23617 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 236177 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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