Healthcare Provider Details

I. General information

NPI: 1982151577
Provider Name (Legal Business Name): COMPLETE CARE MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 PEACH GROVE LN
MONTROSS VA
22520-2756
US

IV. Provider business mailing address

41 PEACH GROVE LN
MONTROSS VA
22520-2756
US

V. Phone/Fax

Practice location:
  • Phone: 804-410-3322
  • Fax: 804-627-0010
Mailing address:
  • Phone: 804-410-3322
  • Fax: 804-627-0010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number0101236987
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number010300694
License Number StateVA

VIII. Authorized Official

Name: MS. ASHLEY K WILLIAMS
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 804-823-7707