Healthcare Provider Details

I. General information

NPI: 1760039010
Provider Name (Legal Business Name): CHRISTINE BLAIR-WALLACE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 08/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

788 BELLWOOD RD
HAMPTON VA
23666-2806
US

IV. Provider business mailing address

788 BELLWOOD RD
HAMPTON VA
23666-2806
US

V. Phone/Fax

Practice location:
  • Phone: 757-285-8392
  • Fax:
Mailing address:
  • Phone: 757-285-8392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: