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NPI Code Detail

MEDICARE: CENTRA HEALTH PROFESSIONAL SERVICES, LLC

MEDICARE: CENTRA HEALTH PROFESSIONAL SERVICES, 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
1207Q00000XFamily Medicine Physician

General Provider Information

NPI Number : 1659315943
Entity Type Code : Organization
Provider Name (Legal Business Name) : CENTRA HEALTH PROFESSIONAL SERVICES, LLC
Provider Business Mailing Address
First Line : 1204 FENWICK DR
Second Line :
City : LYNCHBURG
State : VA
Zip : 24502-2112
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 104 CAROLINA AVE
Second Line :
City : BROOKNEAL
State : VA
Zip : 24528-2643
Country : US
Telephone Number : 434-376-2325
Fax Number :
Authorized Official
Title or Position : DIRECTOR
Name : TAMMY TWEEDY
Credential :
Telephone Number : 434-947-5047
Provider Enumeration Date : 06/16/2006
Last Update Date : 03/04/2008

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Directions to “CENTRA HEALTH PROFESSIONAL SERVICES, LLC ” Practice Location

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