Healthcare Provider Details

I. General information

NPI: 1700627130
Provider Name (Legal Business Name): EVENTUS WH MID-ATLANTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2024
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 BROWNS HILL CT
MIDLOTHIAN VA
23114-9510
US

IV. Provider business mailing address

PO BOX 1431 DEPT 405
CHARLOTTE NC
28201-1431
US

V. Phone/Fax

Practice location:
  • Phone: 855-743-2247
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: BRADLEY GOAD
Title or Position: OWNER
Credential: DO
Phone: 855-743-2247