Healthcare Provider Details

I. General information

NPI: 1730400664
Provider Name (Legal Business Name): CENTRA HEALTH PROFESSIONAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2010
Last Update Date: 08/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 EXECUTIVE DR
DANVILLE VA
24541-4101
US

IV. Provider business mailing address

1204 FENWICK DR
LYNCHBURG VA
24502-2112
US

V. Phone/Fax

Practice location:
  • Phone: 434-797-1383
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: ARTHUR LEAVITT
Title or Position: VP PRACTICE MANAGEMENT
Credential:
Phone: 434-200-3656