Healthcare Provider Details

I. General information

NPI: 1508153453
Provider Name (Legal Business Name): JA CANTU SERVICE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 COMMONWEALTH DR
CHARLOTTESVILLE VA
22901-2338
US

IV. Provider business mailing address

1911 COMMONWEALTH DR
CHARLOTTESVILLE VA
22901-2338
US

V. Phone/Fax

Practice location:
  • Phone: 434-295-4367
  • Fax: 434-971-9733
Mailing address:
  • Phone: 434-295-4367
  • Fax: 434-971-9733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104555910
License Number StateVA

VIII. Authorized Official

Name: DR. JOE A CANTU
Title or Position: MEMBER OWNER
Credential: D.C.
Phone: 434-295-4367