1750588505 NPI number — PRINCE WILLIAM ORTHOTICS & PROSTHETICS LLC

Table of content: BRENT ERIC HAVEY DDS (NPI 1003895996)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750588505 NPI number — PRINCE WILLIAM ORTHOTICS & PROSTHETICS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRINCE WILLIAM ORTHOTICS & PROSTHETICS 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:
1750588505
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10322 BATTLEVIEW PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANASSAS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20109-2338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-368-7967
Provider Business Mailing Address Fax Number:
703-368-7867

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10322 BATTLEVIEW PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANASSAS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20109-2338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-368-7967
Provider Business Practice Location Address Fax Number:
703-368-7867
Provider Enumeration Date:
06/27/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GARNEY
Authorized Official First Name:
ALBERT
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
703-386-7967

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 015167912 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 305536 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 331805 . This is a "AMERIGROUP" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 9703085 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 014937300 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".