MEDICARE: CAROLINE CHRISTIAN HEALTH CENTER

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	208000000X	Pediatrics Physician	0101231223	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215128590
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLINE CHRISTIAN HEALTH CENTER

Provider Business Mailing Address
First Line	:	P.O. BOX 216
Second Line	:
City	:	LADYSMITH
State	:	VA
Zip	:	22501-0216
Country	:	US
Telephone Number	:	804-448-1380
Fax Number	:

Provider Business Practice Location Address
First Line	:	18048 JEFFERSON DAVIS HWY
Second Line	:
City	:	RUTHER GLEN
State	:	VA
Zip	:	22546-2922
Country	:	US
Telephone Number	:	804-448-1380
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. BRANDI GRAHAM
Credential	:
Telephone Number	:	804-448-1380

Provider Enumeration Date	:	08/05/2007
Last Update Date	:	08/05/2007

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