Healthcare Provider Details

I. General information

NPI: 1184025439
Provider Name (Legal Business Name): CH VA COLLABORATIVE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2014
Last Update Date: 02/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4099 BASSWOOD RD
DISPUTANTA VA
23842-4517
US

IV. Provider business mailing address

4055 VALLEY VIEW LN SUITE 400
DALLAS TX
75244-5074
US

V. Phone/Fax

Practice location:
  • Phone: 571-781-7001
  • Fax: 888-722-4282
Mailing address:
  • Phone: 972-715-3800
  • Fax: 888-722-4282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MELISSA M COOKE
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 972-715-3808