1861488090 NPI number — N & R OF VIENNA, LLC

Table of content: (NPI 1861488090)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861488090 NPI number — N & R OF VIENNA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
N & R OF VIENNA, 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:
1861488090
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
512 11TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIENNA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62995-1522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-658-2951
Provider Business Mailing Address Fax Number:
618-658-6404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
512 11TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIENNA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62995-1522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-658-2951
Provider Business Practice Location Address Fax Number:
618-658-6404
Provider Enumeration Date:
09/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WATKINS
Authorized Official First Name:
STEVE
Authorized Official Middle Name:
W
Authorized Official Title or Position:
CEO/ MANAGER
Authorized Official Telephone Number:
618-658-2951

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  0045302 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 32131100 . This is a "STATE ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 954715603002 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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