=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023253978
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWEST SERVICES CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2008
-----------------------------------------------------
Last Update Date | 12/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 GALLBUSH RD
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23322-2046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-560-2667
-----------------------------------------------------
Fax | 703-842-6167
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 GALLBUSH RD
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23322-2046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-560-2667
-----------------------------------------------------
Fax | 703-842-6167
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. CHARLES BAKER SR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-560-2667
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 2705125637
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------