1104228006 NPI number — SQUARE ONE FAMILY NETWORKS CORP.

Table of content: (NPI 1104228006)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104228006 NPI number — SQUARE ONE FAMILY NETWORKS CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SQUARE ONE FAMILY NETWORKS CORP.
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:
1104228006
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1708 LOCUST AVE STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRMONT
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26554-1332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-694-7636
Provider Business Mailing Address Fax Number:
888-977-2130

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1708 LOCUST AVE STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRMONT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26554-1332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-694-7636
Provider Business Practice Location Address Fax Number:
888-977-2130
Provider Enumeration Date:
09/23/2014

Additional Information

Authorized Official

Authorized Official Last Name:
DODD
Authorized Official First Name:
JAYME
Authorized Official Middle Name:
DAWN
Authorized Official Title or Position:
OWNER, EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
304-657-8943

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , with the licence number:  AP00944042 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 252Y00000X , with the licence number: 332608 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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