1780675702 NPI number — KING GEORGE LIFE CARE, LLC

Table of content: (NPI 1780675702)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780675702 NPI number — KING GEORGE LIFE CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KING GEORGE LIFE CARE, 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:
1780675702
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3131 ELECTRIC RD
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:
24018-6427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-774-4263
Provider Business Mailing Address Fax Number:
540-774-0780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10051 FOXES WAY
Provider Second Line Business Practice Location Address:
BOX 495
Provider Business Practice Location Address City Name:
KING GEORGE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22485
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-775-4000
Provider Business Practice Location Address Fax Number:
540-775-3637
Provider Enumeration Date:
10/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GALLANT
Authorized Official First Name:
CASSANDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
COMPLIANCE & PRIVACY OFFICER
Authorized Official Telephone Number:
540-774-4263

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH2577 , 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: 4953002 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200515607 . This is a "FEDERAL BLACK LUNG ID" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 180508 . This is a "ANTHEM BCBS PROVIDER ID" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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