Healthcare Provider Details

I. General information

NPI: 1770980757
Provider Name (Legal Business Name): PHYSIATRY-SPORTS & FAMILY MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2014
Last Update Date: 10/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2147 OLD GREENBRIER RD SUITE B
CHESAPEAKE VA
23320-2635
US

IV. Provider business mailing address

PO BOX 15763
CHESAPEAKE VA
23328-5763
US

V. Phone/Fax

Practice location:
  • Phone: 757-366-0200
  • Fax:
Mailing address:
  • Phone: 757-366-0200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number0101241301
License Number StateVA

VIII. Authorized Official

Name: DR. TRAVIS LEE
Title or Position: PRESIDENT
Credential:
Phone: 757-366-0200