Healthcare Provider Details

I. General information

NPI: 1881852630
Provider Name (Legal Business Name): DEBRA CLEMENT CUPP RTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1463 STRIPERS COVE RD
GOODVIEW VA
24095-3515
US

IV. Provider business mailing address

1463 STRIPERS COVE RD
GOODVIEW VA
24095-3515
US

V. Phone/Fax

Practice location:
  • Phone: 540-296-0814
  • Fax:
Mailing address:
  • Phone: 540-296-0814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number150305
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License NumberCRT55220
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: