1750451357 NPI number — FOUR LEAF CLOVER, INC

Table of content: (NPI 1750451357)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750451357 NPI number — FOUR LEAF CLOVER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUR LEAF CLOVER, 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:
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:
1750451357
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3280 HWY 69
Provider Second Line Business Mailing Address:
SUITE II
Provider Business Mailing Address City Name:
HAYESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28904-1007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-777-3203
Provider Business Mailing Address Fax Number:
828-389-9779

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3280 HWY 69
Provider Second Line Business Practice Location Address:
SUITE II
Provider Business Practice Location Address City Name:
HAYESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28904-1007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-777-3203
Provider Business Practice Location Address Fax Number:
828-389-9778
Provider Enumeration Date:
11/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SWEENEY
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
F.
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
888-777-3203

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  2004-16341 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: 1035023 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000965346A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100454120 A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200003930 A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 464074 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001963766 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4582201 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4503699 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 145573501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 146926741 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9000515800 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00440785 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 600678485 . This is a "NC STATE ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 65-509-5427-001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003107887 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 182741 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200408900 A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2254804 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7703099 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7777027 00 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: R8517 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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