Healthcare Provider Details

I. General information

NPI: 1619966876
Provider Name (Legal Business Name): LUIS MANUEL ORTIZ LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 01/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

576 JEFFERSON AVE MCDONALD ARMY HEALTH CENTER
FORT EUSTIS VA
23604-5548
US

IV. Provider business mailing address

111 SUMMEGLEN RIDGE
NEWPORT NEWS VA
23602-8319
US

V. Phone/Fax

Practice location:
  • Phone: 757-314-7522
  • Fax: 757-314-7524
Mailing address:
  • Phone: 757-249-8252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number0002048061
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: