Healthcare Provider Details

I. General information

NPI: 1669606802
Provider Name (Legal Business Name): ANGIE CAIN IDMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2009
Last Update Date: 01/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 MEDICAL GROUP 77 NEALLY AVE
JOINT BASE LANGLEY-EUSTIS VA
23665-2040
US

IV. Provider business mailing address

633 MEDICAL GROUP 77 NEALLY AVE
JOINT BASE LANGLEY-EUSTIS VA
23665-2040
US

V. Phone/Fax

Practice location:
  • Phone: 757-764-2109
  • Fax:
Mailing address:
  • Phone: 757-764-2109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: