Healthcare Provider Details

I. General information

NPI: 1679049944
Provider Name (Legal Business Name): TAKEDA HINTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2018
Last Update Date: 12/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22086 BATEMAN ST
COURTLAND VA
23837-1005
US

IV. Provider business mailing address

PO BOX 532
COURTLAND VA
23837-0532
US

V. Phone/Fax

Practice location:
  • Phone: 757-556-7314
  • Fax:
Mailing address:
  • Phone: 757-556-7314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number83-1948065
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: