1851656870 NPI number — COEBURN CLINIC, INC

Table of content: YELIZAVETA BULUCHEVSKAYA PT, DPT, CSCS (NPI 1275215451)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851656870 NPI number — COEBURN CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COEBURN CLINIC, 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:
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:
1851656870
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1136
Provider Second Line Business Mailing Address:
116 CENTER ST
Provider Business Mailing Address City Name:
COEBURN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24230-1136
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-395-6244
Provider Business Mailing Address Fax Number:
276-395-3058

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
116 CENTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COEBURN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24230-2200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-395-6244
Provider Business Practice Location Address Fax Number:
276-395-3058
Provider Enumeration Date:
07/05/2012

Additional Information

Authorized Official

Authorized Official Last Name:
KANWAL
Authorized Official First Name:
GURCHARAN
Authorized Official Middle Name:
SINGH
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
276-395-6244

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  0101021217 , 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: PENDING . This is a "NUMBERS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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