1891044657 NPI number — DRYNACHAN LLC

Table of content: (NPI 1891044657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891044657 NPI number — DRYNACHAN LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DRYNACHAN 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:
1891044657
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14121 PARKE LONG CT
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
CHANTILLY
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20151-1647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
571-449-3585
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14121 PARKE LONG CT
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
CHANTILLY
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20151-1647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
571-449-3585
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/07/2012

Additional Information

Authorized Official

Authorized Official Last Name:
WISE
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
571-449-2928

Provider Taxonomy Codes

  • Taxonomy code: 251J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1891044657 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300001898 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1891055657 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500040770 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 18159900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1991044657 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003185092A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP7738 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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