Healthcare Provider Details

I. General information

NPI: 1558049429
Provider Name (Legal Business Name): ETHOS HOUSE CALLS PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 07/10/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7337 OLD CAMP RD
LANEXA VA
23089-5133
US

IV. Provider business mailing address

7337 OLD CAMP RD
LANEXA VA
23089-5133
US

V. Phone/Fax

Practice location:
  • Phone: 757-719-0621
  • Fax:
Mailing address:
  • Phone: 757-719-0621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. JOAN ELIZABETH BENTON
Title or Position: NP
Credential: NP-C
Phone: 757-719-0621