Healthcare Provider Details

I. General information

NPI: 1023640349
Provider Name (Legal Business Name): ULTIMATE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2020
Last Update Date: 03/09/2020
Certification Date: 03/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1437 SAMS DR STE 122
CHESAPEAKE VA
23320-4587
US

IV. Provider business mailing address

1437 SAMS DR STE 122
CHESAPEAKE VA
23320-4587
US

V. Phone/Fax

Practice location:
  • Phone: 757-549-3668
  • Fax:
Mailing address:
  • Phone: 757-549-3668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RYAN SADINSKI
Title or Position: PARTENER
Credential:
Phone: 757-537-6050