Healthcare Provider Details

I. General information

NPI: 1306941505
Provider Name (Legal Business Name): CHILDREN'S CLINIC LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 08/28/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 MANHATTAN SQUARE
HAMPTON VA
23666
US

IV. Provider business mailing address

23 MANHATTAN SQUARE
HAMPTON VA
23666
US

V. Phone/Fax

Practice location:
  • Phone: 757-595-0358
  • Fax: 757-595-6745
Mailing address:
  • Phone: 757-595-0358
  • Fax: 757-595-6745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101035213
License Number StateVA

VIII. Authorized Official

Name: DR. JULIAN H BLALOCK JR JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 757-595-0358