1770830804 NPI number — GENESIS HEALTH AND WELLNESS GROUP

Table of content: (NPI 1770830804)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770830804 NPI number — GENESIS HEALTH AND WELLNESS GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENESIS HEALTH AND WELLNESS GROUP
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:
1770830804
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
607 W DUE WEST AVE
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37115-4431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-891-4903
Provider Business Mailing Address Fax Number:
615-864-8671

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
607 W DUE WEST AVE
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37115-4431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-891-4903
Provider Business Practice Location Address Fax Number:
615-864-8671
Provider Enumeration Date:
08/08/2012

Additional Information

Authorized Official

Authorized Official Last Name:
PUCKETT
Authorized Official First Name:
ALLISION
Authorized Official Middle Name:
PATRICE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
615-585-9305

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP3300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1530899 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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