1699777979 NPI number — ADVANCE GROUP L.L.C.

Table of content: (NPI 1699777979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699777979 NPI number — ADVANCE GROUP L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCE GROUP L.L.C.
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:
1699777979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1328 REISTERSTOWN RD
Provider Second Line Business Mailing Address:
STE C
Provider Business Mailing Address City Name:
PIKESVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21208-3838
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-580-2040
Provider Business Mailing Address Fax Number:
410-580-2060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1328 REISTERSTOWN RD
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
PIKESVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21208-3838
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-580-2040
Provider Business Practice Location Address Fax Number:
410-580-2060
Provider Enumeration Date:
06/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PASTUSHENKO
Authorized Official First Name:
YEDUARD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
410-580-2040

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  R2173 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1000039562 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 383603700 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 406372400 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 383602900 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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