Healthcare Provider Details

I. General information

NPI: 1972758084
Provider Name (Legal Business Name): MR. LEVONDIA DALE PARKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2008
Last Update Date: 11/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3477 WOODBAUGH DR
CHESAPEAKE VA
23321-4825
US

IV. Provider business mailing address

3477 WOODBAUGH DR
CHESAPEAKE VA
23321-4825
US

V. Phone/Fax

Practice location:
  • Phone: 757-515-7134
  • Fax: 757-484-6090
Mailing address:
  • Phone: 757-515-7134
  • Fax: 757-484-6090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number8003849
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: