Provider Demographics
NPI:1457769762
Name:JH ORG 07302014
Entity Type:Organization
Organization Name:JH ORG 07302014
Other - Org Name:SMOKE 04/04
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:MR
Authorized Official - First Name:TEST
Authorized Official - Middle Name:
Authorized Official - Last Name:ORG-A
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:555-111-2222
Mailing Address - Street 1:5225 23RD AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-7927
Mailing Address - Country:US
Mailing Address - Phone:123-456-7890
Mailing Address - Fax:
Practice Address - Street 1:6801 KENNEDY RD
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20187-3995
Practice Address - Country:US
Practice Address - Phone:324-324-3434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-30
Last Update Date:2022-12-28
Deactivation Date:2020-08-16
Deactivation Code:
Reactivation Date:2020-08-16
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes281P00000XHospitalsChronic Disease HospitalGroup - Multi-Specialty
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No251J00000XAgenciesNursing CareGroup - Multi-Specialty
No273Y00000XHospital UnitsRehabilitation UnitGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZSDFSDFMedicaid
=========OtherTEST