Healthcare Provider Details

I. General information

NPI: 1477731925
Provider Name (Legal Business Name): CHIPPENHAM & JOHNSTON WILLIS SPORTS MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2008
Last Update Date: 02/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 FESTIVAL PARK PLAZA
CHESTER VA
23831
US

IV. Provider business mailing address

500 HIOAKS RD SUITE A
RICHMOND VA
23225-4061
US

V. Phone/Fax

Practice location:
  • Phone: 804-560-6500
  • Fax: 804-560-6505
Mailing address:
  • Phone: 804-560-6500
  • Fax: 804-560-6505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: HUNTER LEE DURVIN
Title or Position: MANAGER
Credential: ATC
Phone: 804-560-6511