1720324312 NPI number — TAYLORS ENHANCED LIVING III INC

Table of content: (NPI 1720324312)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720324312 NPI number — TAYLORS ENHANCED LIVING III INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAYLORS ENHANCED LIVING III 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:
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:
1720324312
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1617 BOULEVARD
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
COLONIAL HEIGHTS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23834-2329
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-733-8847
Provider Business Mailing Address Fax Number:
804-732-4963

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
589 S CRATER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PETERSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23803-5263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-733-4114
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/31/2012

Additional Information

Authorized Official

Authorized Official Last Name:
STARKE
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
C
Authorized Official Title or Position:
EXE DIR
Authorized Official Telephone Number:
804-586-1587

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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