Healthcare Provider Details

I. General information

NPI: 1043662828
Provider Name (Legal Business Name): CENTRA HEALTH PROFESSIONAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2016
Last Update Date: 07/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 PARK AVENUE
DANVILLE VA
24541-9998
US

IV. Provider business mailing address

414 PARK AVENUE
DANVILLE VA
24541-9998
US

V. Phone/Fax

Practice location:
  • Phone: 434-791-1562
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA LARKIN
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 434-200-5047