1740467463 NPI number — THERAPY PROVIDERS SERVICE ORGANIZATION, LLC

Table of content: (NPI 1740467463)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740467463 NPI number — THERAPY PROVIDERS SERVICE ORGANIZATION, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THERAPY PROVIDERS SERVICE ORGANIZATION, 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:
1740467463
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
414 PENCO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEIRTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26062-3822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-723-3780
Provider Business Mailing Address Fax Number:
304-723-4110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
47454 ROUTE 52
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KERMIT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25674-8052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-393-4072
Provider Business Practice Location Address Fax Number:
304-393-4074
Provider Enumeration Date:
01/24/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MASCIO
Authorized Official First Name:
MARK
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
304-723-3780

Provider Taxonomy Codes

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

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

  • Identifier: 002013370 . This is a "MOUNTAIN STATE BCBS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 3810011333 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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