Healthcare Provider Details

I. General information

NPI: 1154860310
Provider Name (Legal Business Name): COMPASSIONATE CARE PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2017
Last Update Date: 04/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 HOSPITAL DR STE 101
MARTINSVILLE VA
24112-1945
US

IV. Provider business mailing address

315 HOSPITAL DR STE 101
MARTINSVILLE VA
24112-1945
US

V. Phone/Fax

Practice location:
  • Phone: 276-252-1948
  • Fax:
Mailing address:
  • Phone: 276-252-1948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number0101056392
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101056392
License Number StateVA

VIII. Authorized Official

Name: DR. LUIS A MATOS
Title or Position: SUPERVISING PHYSICIAN
Credential: MD
Phone: 276-252-1948