Healthcare Provider Details

I. General information

NPI: 1578797643
Provider Name (Legal Business Name): VENSON MATTHEW GRAVES IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2009
Last Update Date: 05/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USS THEODORE ROOSEVELT # 71 CVN-71
FPO AE
09599-2871
US

IV. Provider business mailing address

USS THEODORE ROOSEVELT # 71 CVN-71
FPO AE
09599-2871
US

V. Phone/Fax

Practice location:
  • Phone: 757-446-7633
  • Fax:
Mailing address:
  • Phone: 757-446-7633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246QC2700X
TaxonomyCytotechnology Specialist/Technologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: