Basic Information
Provider Information | |||||||||
NPI: | 1245263359 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HP/STANDARDSVILLE, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EVERGREENE NURSING CARE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 925 N POINT PKWY | ||||||||
Address2: | SUITE 440 | ||||||||
City: | ALPHARETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300055210 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7706190866 | ||||||||
FaxNumber: | 7708702892 | ||||||||
Practice Location | |||||||||
Address1: | 355 WILLIAM MILLS DR | ||||||||
Address2: |   | ||||||||
City: | STANARDSVILLE | ||||||||
State: | VA | ||||||||
PostalCode: | 229733055 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4349854434 | ||||||||
FaxNumber: | 4349852499 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/09/2006 | ||||||||
LastUpdateDate: | 08/05/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ANSTIS | ||||||||
AuthorizedOfficialFirstName: | LOUANN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRIVACY OFFICER | ||||||||
AuthorizedOfficialTelephone: | 7706190866 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH2551 | VA | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 004953436 | 05 | VA |   | MEDICAID |