1891798930 NPI number — UCHEE PINES LIFESTYLE CENTER

Table of content: (NPI 1891798930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891798930 NPI number — UCHEE PINES LIFESTYLE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UCHEE PINES LIFESTYLE CENTER
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:
ANVWODI
Provider Other Organization Name Type Code:
5
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:
1891798930
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 UCHEE PINES ROAD
Provider Second Line Business Mailing Address:
#75
Provider Business Mailing Address City Name:
SEALE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36875-5715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-855-4763
Provider Business Mailing Address Fax Number:
334-855-9014

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 UCHEE PINES RD
Provider Second Line Business Practice Location Address:
LOT 75
Provider Business Practice Location Address City Name:
SEALE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36875-5726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-855-4763
Provider Business Practice Location Address Fax Number:
334-855-9014
Provider Enumeration Date:
05/23/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HORSLEY
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
IRWIN
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
334-855-4764

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  00019762 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: 4123 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: 025873 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: 007539 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: 04837 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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