Basic Information
| Provider Information | |||||||||
| NPI: | 1558697235 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TWIN COUNTY REGIONAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OUTPATIENT REHABILITATION SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | GALAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243332227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2762361675 | ||||||||
| FaxNumber: | 2762361715 | ||||||||
| Practice Location | |||||||||
| Address1: | 607 GLENDALE RD | ||||||||
| Address2: | |||||||||
| City: | GALAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243332209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2762361675 | ||||||||
| FaxNumber: | 2762363399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2009 | ||||||||
| LastUpdateDate: | 10/30/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MONTGOMERY | ||||||||
| AuthorizedOfficialFirstName: | NELSON | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2762361620 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 007694 | 01 | VA | BLUE CROSS | OTHER | 0490115 | 05 | VA | MEDICAID |