Healthcare Provider Details

I. General information

NPI: 1831242353
Provider Name (Legal Business Name): COMMONWEALTH PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 12/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 INNSLAKE DR STE 308
GLEN ALLEN VA
23060
US

IV. Provider business mailing address

8002 DISCOVERY DR STE 410
RICHMOND VA
23229
US

V. Phone/Fax

Practice location:
  • Phone: 804-521-5310
  • Fax: 804-521-5312
Mailing address:
  • Phone: 804-288-0399
  • Fax: 804-288-0088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. CHERYL DANIEL
Title or Position: BILLING MANAGER
Credential:
Phone: 804-288-0399