Healthcare Provider Details

I. General information

NPI: 1144522624
Provider Name (Legal Business Name): ROBERT R EGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2010
Last Update Date: 03/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2512 LAKESIDE WOODS DR
BUMPASS VA
23024-9685
US

IV. Provider business mailing address

2512 LAKESIDE WOODS DR
BUMPASS VA
23024-9685
US

V. Phone/Fax

Practice location:
  • Phone: 540-878-6669
  • Fax:
Mailing address:
  • Phone: 540-878-6669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number2705134042
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: