1962178269 NPI number — VERSACARE MD, LLC

Table of content: (NPI 1962178269)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962178269 NPI number — VERSACARE MD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VERSACARE MD, 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:
1962178269
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 TROTTERS LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25312-6770
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1260A GREENBRIER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25311-1002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-915-2500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/18/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MCCARTY
Authorized Official First Name:
AMANDA
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER/ADMINISTRATOR
Authorized Official Telephone Number:
304-615-9925

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207QA0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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