1659457158 NPI number — DEREK ENTERPRISES LLC

Table of content: (NPI 1659457158)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659457158 NPI number — DEREK ENTERPRISES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEREK ENTERPRISES 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:
1659457158
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1086 ROUTE 315
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLAINS
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-823-7761
Provider Business Mailing Address Fax Number:
570-822-8033

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 ROTARY DRIVE
Provider Second Line Business Practice Location Address:
VALMONT INDUSTRIAL PARK
Provider Business Practice Location Address City Name:
W HAZLETON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-459-6333
Provider Business Practice Location Address Fax Number:
570-459-5255
Provider Enumeration Date:
10/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CASSETORI
Authorized Official First Name:
DON
Authorized Official Middle Name:
R
Authorized Official Title or Position:
BUSINESS MGR TREAS
Authorized Official Telephone Number:
570-823-7761

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 50042164 . This is a "CAPITAL BCBS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 61915 . This is a "GEISINGER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 118707500 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 315464 . This is a "HEALTH AMERICA HLTH ASSUR" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 5234560 . This is a "AETNA US HEALTHCARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1507382 . This is a "HIGHMARK BCBS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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