Basic Information
| Provider Information | |||||||||
| NPI: | 1962642520 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MANCHESTER VILLAGE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MANCHESTER FIRE DEPT. & RESCUE SQD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 836 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257011407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045211576 | ||||||||
| FaxNumber: | 3045211768 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 E. 5TH ST. | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375493358 | ||||||||
| FaxNumber: | 9375492502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2009 | ||||||||
| LastUpdateDate: | 03/06/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOWMAN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 9377797241 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | 2961595 | 05 | OH | MEDICAID | 000000622255 | 01 | ANTHEM | OTHER |