Healthcare Provider Details

I. General information

NPI: 1780148494
Provider Name (Legal Business Name): CORNEL T BEDWARD RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2019
Last Update Date: 01/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9301 THE NEW RD
CHARLES CITY VA
23030-4424
US

IV. Provider business mailing address

9301 THE NEW RD
CHARLES CITY VA
23030-4424
US

V. Phone/Fax

Practice location:
  • Phone: 804-426-1314
  • Fax:
Mailing address:
  • Phone: 804-426-1314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279P1004X
TaxonomyPulmonary Diagnostics Registered Respiratory Therapist
License Number0117007188
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: