Healthcare Provider Details

I. General information

NPI: 1891922928
Provider Name (Legal Business Name): PRIS,PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 01/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 MEMORIAL AVE SUITE 201B
LYNCHBURG VA
24501-2662
US

IV. Provider business mailing address

2600 MEMORIAL AVE SUITE 201B
LYNCHBURG VA
24501-2662
US

V. Phone/Fax

Practice location:
  • Phone: 434-528-0896
  • Fax: 434-528-0898
Mailing address:
  • Phone: 434-528-0896
  • Fax: 434-528-0898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number0101055485
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number0101055485
License Number StateVA

VIII. Authorized Official

Name: DR. BRENDA SUE WALLER
Title or Position: CEO
Credential: MD
Phone: 434-528-0896