Healthcare Provider Details

I. General information

NPI: 1164720058
Provider Name (Legal Business Name): CENTRA MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2011
Last Update Date: 11/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1280A MAIN ST
ALTAVISTA VA
24517-1465
US

IV. Provider business mailing address

1204 FENWICK DR
LYNCHBURG VA
24502-2112
US

V. Phone/Fax

Practice location:
  • Phone: 434-309-1165
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LEWIS ADDISON
Title or Position: SR VP, CFO
Credential:
Phone: 434-200-3656