Healthcare Provider Details

I. General information

NPI: 1902277619
Provider Name (Legal Business Name): RIVER CROSSING HEALTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2015
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9680 ALEXANDRA NICOLE DR
LORTON VA
22079-3471
US

IV. Provider business mailing address

9680 ALEXANDRA NICOLE DR
LORTON VA
22079-3471
US

V. Phone/Fax

Practice location:
  • Phone: 614-736-3884
  • Fax:
Mailing address:
  • Phone: 614-736-3884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102203356
License Number StateVA

VIII. Authorized Official

Name: DR. IKENNA S NZEOGU
Title or Position: MANAGING PARTNER
Credential: D.O.
Phone: 614-736-3884