1992705545 NPI number — PROACTIVE THERAPY OF VIRGINIA, INC.

Table of content: SUZANNE MARIE GROMNIAK N P (NPI 1336192525)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992705545 NPI number — PROACTIVE THERAPY OF VIRGINIA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROACTIVE THERAPY OF VIRGINIA, 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:
6
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:
1992705545
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:
4716 OLD GETTYSBURG RD
Provider Second Line Business Mailing Address:
LEGAL DEPARTMEN
Provider Business Mailing Address City Name:
MECHANICSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17055-4325
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-972-1139
Provider Business Mailing Address Fax Number:
717-975-9981

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2426 LEE HWY
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
BRISTOL
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24202-5967
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-645-0311
Provider Business Practice Location Address Fax Number:
276-645-0302
Provider Enumeration Date:
07/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
TARVIN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
717-972-1139

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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