Healthcare Provider Details

I. General information

NPI: 1518315902
Provider Name (Legal Business Name): CENTRA MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 05/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 NATIONWIDE DRIVE
LYNCHBURG VA
24502-9998
US

IV. Provider business mailing address

125 NATIONWIDE DR
LYNCHBURG VA
24502-4272
US

V. Phone/Fax

Practice location:
  • Phone: 434-200-3908
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA LARKIN
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 434-200-5047