MEDICARE: VIRGINIA VASCULAR, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1013139047
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIRGINIA VASCULAR, LLC

Provider Business Mailing Address
First Line	:	6015 POPLAR HALL DR STE 308
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23502-3819
Country	:	US
Telephone Number	:	757-594-1032
Fax Number	:

Provider Business Practice Location Address
First Line	:	1031 LOFTIS BLVD
Second Line	:
City	:	NEWPORT NEWS
State	:	VA
Zip	:	23606-2981
Country	:	US
Telephone Number	:	757-594-1032
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE VICE PRESIDENT
Name	:	KENNETH M KRAKAUR
Credential	:
Telephone Number	:	757-594-1031

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	08/22/2020

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