1760495717 NPI number — MEDICAL FACILITIES OF AMERICA XIX

Table of content: (NPI 1760495717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760495717 NPI number — MEDICAL FACILITIES OF AMERICA XIX

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL FACILITIES OF AMERICA XIX
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:
1760495717
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2917 PENN FOREST BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24018-4374
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-989-3618
Provider Business Mailing Address Fax Number:
540-774-9443

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2401 LEE HWY N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PULASKI
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24301-2325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-980-3111
Provider Business Practice Location Address Fax Number:
540-980-2502
Provider Enumeration Date:
08/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
CLAUDE
Authorized Official Middle Name:
NOVEL
Authorized Official Title or Position:
CFO, MFA INC. GENERAL PARTNER
Authorized Official Telephone Number:
540-776-7526

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH2657 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4952944 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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