Healthcare Provider Details

I. General information

NPI: 1114011327
Provider Name (Legal Business Name): VICTORIA ELAINE CHUCHLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

IS COMDT # CG-1122 U.S.COAST GUARD, 2100 2ND ST SW, SUITE 5314
WASHINGTON DC
20593-0001
US

IV. Provider business mailing address

274 GULFSTREAM DR
ELIZABETH CITY NC
27909-6704
US

V. Phone/Fax

Practice location:
  • Phone: 252-335-6460
  • Fax: 252-335-6255
Mailing address:
  • Phone: 252-335-6460
  • Fax: 252-335-6255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: