Healthcare Provider Details

I. General information

NPI: 1053403378
Provider Name (Legal Business Name): PROVIDENCE FAMILY & SPORTS MEDICINE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 05/26/2022
Certification Date: 05/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 EXECUTIVE DR
DANVILLE VA
24541-4101
US

IV. Provider business mailing address

173 EXECUTIVE DR
DANVILLE VA
24541-4101
US

V. Phone/Fax

Practice location:
  • Phone: 434-791-4110
  • Fax: 434-791-4003
Mailing address:
  • Phone: 434-791-4110
  • Fax: 434-791-4003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. LISA CAMPBELL WOOD
Title or Position: OFFICE MANAGER
Credential:
Phone: 434-791-4110