1700892775 NPI number — CAROLYN LYNN ST CLAIR PAC

Table of content: CAROLYN LYNN ST CLAIR PAC (NPI 1700892775)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700892775 NPI number — CAROLYN LYNN ST CLAIR PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ST CLAIR
Provider First Name:
CAROLYN
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

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:
1700892775
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16 WALNUT AVE SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24016-4719
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-345-6468
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4550 LEE HWY STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24084-3802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-440-3170
Provider Business Practice Location Address Fax Number:
540-674-5544
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  0110001841 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1700892775 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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