Healthcare Provider Details

I. General information

NPI: 1821370321
Provider Name (Legal Business Name): KENANVILLE SURGICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2011
Last Update Date: 09/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 WIMBLEDON SQ STE C
CHESAPEAKE VA
23320-4945
US

IV. Provider business mailing address

109 WIMBLEDON SQ STE C
CHESAPEAKE VA
23320-4945
US

V. Phone/Fax

Practice location:
  • Phone: 757-436-3630
  • Fax:
Mailing address:
  • Phone: 757-436-3630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. MOHIB N.I. GHOBRIAL
Title or Position: OWNER
Credential: M.D.
Phone: 757-436-3630