1750405650 NPI number — WANDA SUE CHAFIN

Table of content: WANDA SUE CHAFIN (NPI 1750405650)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750405650 NPI number — WANDA SUE CHAFIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAFIN
Provider First Name:
WANDA
Provider Middle Name:
SUE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1750405650
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3700
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37602-3700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-952-2122
Provider Business Mailing Address Fax Number:
423-952-2145

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
245 MEDICAL PARK DR
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24354-1100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-378-3300
Provider Business Practice Location Address Fax Number:
276-378-1265
Provider Enumeration Date:
03/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  0024106427 , 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)

  • Identifier: 1750405650 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q008368 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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