1750305033 NPI number — GRAYSON FACILITY OPERATIONS, LLC

Table of content: (NPI 1750305033)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750305033 NPI number — GRAYSON FACILITY OPERATIONS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAYSON FACILITY OPERATIONS, 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:
1750305033
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 857
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDEPENDENCE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24348-0857
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-773-0303
Provider Business Mailing Address Fax Number:
276-773-0404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 S. INDEPENDENCE AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24348-3857
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-773-0303
Provider Business Practice Location Address Fax Number:
276-773-0404
Provider Enumeration Date:
07/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LEHNER
Authorized Official First Name:
TIM
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
770-698-9040

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3001495490 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1750305033 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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