Basic Information
| Provider Information | |||||||||
| NPI: | 1437393857 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VALLEY REGIONAL ENTERPRISES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VALLEY HOME CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1910 | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226048060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5405364310 | ||||||||
| FaxNumber: | 5405362396 | ||||||||
| Practice Location | |||||||||
| Address1: | 480 EAST SOUTH COMMERCE AVE | ||||||||
| Address2: | |||||||||
| City: | FRONT ROYAL | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226303093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406357444 | ||||||||
| FaxNumber: | 5406357787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2009 | ||||||||
| LastUpdateDate: | 04/21/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WISEMAN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | DIVISION CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 5405364310 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VALLEY REGIONAL ENTERPRISES | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BX2000X | 0206008342 | VA | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies |
ID Information
| ID | Type | State | Issuer | Description | 9133887 | 05 | VA | MEDICAID | 0144683002 | 05 | WV | MEDICAID | 076082 | 01 | BC/BS | OTHER |