Healthcare Provider Details

I. General information

NPI: 1962443721
Provider Name (Legal Business Name): FORT CHISWELL FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 01/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 FORT CHISWELL RD FORT CHISWELL PLAZA SUITE D
MAX MEADOWS VA
24360-3986
US

IV. Provider business mailing address

245 FORT CHISWELL RD FORT CHISWELL PLAZA SUITE D
MAX MEADOWS VA
24360-3986
US

V. Phone/Fax

Practice location:
  • Phone: 276-637-4300
  • Fax: 276-637-4301
Mailing address:
  • Phone: 276-637-4300
  • Fax: 276-637-4301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KENNETH WASHINGTON
Title or Position: VP
Credential:
Phone: 703-650-2907