1881850857 NPI number — GREATER BOONE DIALYSIS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881850857 NPI number — GREATER BOONE DIALYSIS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREATER BOONE DIALYSIS, 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:
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:
1881850857
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24 MCCORKLE AVE SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH CHARLESTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25303-1476
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-720-2222
Provider Business Mailing Address Fax Number:
304-720-2322

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 4TH ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DANVILLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-720-3456
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/30/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CARPER
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
304-720-2222

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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