Healthcare Provider Details

I. General information

NPI: 1497900047
Provider Name (Legal Business Name): CENTRA HEALTH PROFESSIONAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2008
Last Update Date: 11/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1039 MAYBERRY CROSSING DRIVE
MONETA VA
24121
US

IV. Provider business mailing address

1204 FENWICK DR
LYNCHBURG VA
24502-2112
US

V. Phone/Fax

Practice location:
  • Phone: 540-297-7840
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: TAMMY TWEEDY
Title or Position: REGIONAL DIRECTOR
Credential:
Phone: 434-200-3656