1467497347 NPI number — STREET HOME MEDICAL, INC

Table of content: (NPI 1467497347)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467497347 NPI number — STREET HOME MEDICAL, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STREET HOME MEDICAL, 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:
1467497347
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1544 WATSON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARNER ROBINS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31093-3432
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-922-2889
Provider Business Mailing Address Fax Number:
478-922-9120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1544 WATSON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARNER ROBINS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31093-3432
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-922-2889
Provider Business Practice Location Address Fax Number:
478-922-9120
Provider Enumeration Date:
06/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STREET
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
C.E.O.
Authorized Official Telephone Number:
478-922-2889

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  62133 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000545982A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com