1649677170 NPI number — SCLTDI JV, LLC

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 1649677170 NPI number — SCLTDI JV, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SCLTDI JV, 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:
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:
1649677170
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 746001
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-6001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12021 PENNSYLVANIA ST
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
THORNTON
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80241-3150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-991-2021
Provider Business Practice Location Address Fax Number:
303-991-2026
Provider Enumeration Date:
11/26/2014

Additional Information

Authorized Official

Authorized Official Last Name:
ROELLE
Authorized Official First Name:
KATRINA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF CREDENTIALING
Authorized Official Telephone Number:
614-689-1691

Provider Taxonomy Codes

  • Taxonomy code: 293D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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