Healthcare Provider Details

I. General information

NPI: 1346859188
Provider Name (Legal Business Name): CPRPM, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 COLD BRANCH RD
FOREST VA
24551-2111
US

IV. Provider business mailing address

113 COLD BRANCH RD
FOREST VA
24551-2111
US

V. Phone/Fax

Practice location:
  • Phone: 434-546-3576
  • Fax:
Mailing address:
  • Phone: 434-546-3576
  • Fax:

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: DR. CRAIG PETRY
Title or Position: OWNER/PRESIDENT
Credential: MD
Phone: 434-546-3576