Healthcare Provider Details

I. General information

NPI: 1215629100
Provider Name (Legal Business Name): JB JAMES FAVORITE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 05/22/2023
Certification Date: 05/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 APPALACHIAN CT
CHESAPEAKE VA
23320-1620
US

IV. Provider business mailing address

604 APPALACHIAN CT
CHESAPEAKE VA
23320-1620
US

V. Phone/Fax

Practice location:
  • Phone: 843-231-9865
  • Fax:
Mailing address:
  • Phone: 843-231-9865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number2081S0010X
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: