NPI |
1417345471 |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Entity Type Code |
2 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Employer Identification Number EIN |
|
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Provider Organization Name Legal Business Name |
WJBD VA MEDICAL FACILITY |
|
Provider First Line Business Practice Location Address |
6439 GARNERS FERRY RD |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
Provider Business Practice Location Address City Name |
COLUMBIA |
The city name in the location address of the provider being identified. |
Provider Business Practice Location Address State Name |
SC |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address Postal Code |
292091638 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Telephone Number |
8037764000 |
The telephone number associated with the location address of the provider being identified. |
Provider Enumeration Date |
12/29/2014 |
The date the provider was assigned a unique identifier (assigned an NPI). |
Last Update Date |
12/29/2014 |
The date that a record was last updated or changed. |
Authorized Official Last Name |
COLVIN |
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
Authorized Official First Name |
SHERREE |
The first name of the authorized official. |
Authorized Official Middle Name |
LOUISE |
The middle name of the authorized official. |
Authorized Official Title or Position |
CHIEF SOCIAL WORK |
The title or position of the authorized official. |
Authorized Official Telephone Number |
8037764000 |
The 10-position telephone number of the authorized official. |
Healthcare Provider Taxonomy Code 1 |
282N00000X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Provider License Number 1 |
6289 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Provider License Number State Code 1 |
SC |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
Is Organization Subpart |
N |
|
Authorized Official Name Prefix Text |
MRS. |
|
Authorized Official Credential Text |
LISW-CP |
|