1952465288 NPI number — BOSTWICK LABORATORIES, INC.

Table of content: (NPI 1952465288)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952465288 NPI number — BOSTWICK LABORATORIES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOSTWICK LABORATORIES, 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:
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:
1952465288
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
10/06/2011
NPI Reactivation Date:
02/27/2012

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 403751
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30384-3751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-967-9225
Provider Business Mailing Address Fax Number:
804-239-1954

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4851 LAKE BROOK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLEN ALLEN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23060-9233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-967-9225
Provider Business Practice Location Address Fax Number:
804-239-1954
Provider Enumeration Date:
12/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOSTWICK
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
GRANGER
Authorized Official Title or Position:
CEO, PRESIDENT, CHIEF MED. OFFICER
Authorized Official Telephone Number:
804-967-9225

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 036874800 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0578229 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100503849 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1198722 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 120124700 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 164650710 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 419300000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6701112000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 690000006 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010062811 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2420571 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4582490 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0421311 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200262210A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 32287232 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 409261900 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 706132305 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7123995 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8069026 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: L00184 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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