1659515815 NPI number — THERAPY SUPPORT, INC.

Table of content: (NPI 1659515815)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659515815 NPI number — THERAPY SUPPORT, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THERAPY SUPPORT, INC.
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:
1659515815
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2803 N OAK GROVE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65803-4976
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-887-5873
Provider Business Mailing Address Fax Number:
417-380-5205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4300 SIMON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOARDMAN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44512-1326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-953-0553
Provider Business Practice Location Address Fax Number:
330-953-0554
Provider Enumeration Date:
04/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PAVLIN
Authorized Official First Name:
RUSCELL
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
MEDICARE MANAGER
Authorized Official Telephone Number:
417-380-5105

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  HMER. 22583 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BX2000X , with the licence number: RSOX. 021908350 , 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)

  • Identifier: 160813 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 056142 . This is a "ANTHEM BLUE CROSS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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