Healthcare Provider Details

I. General information

NPI: 1568126795
Provider Name (Legal Business Name): WELLPATH COMMUNITY CARE CENTERS OF VIRGINIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2021
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11049 WARWICK BLVD
NEWPORT NEWS VA
23601-3226
US

IV. Provider business mailing address

1283 MURFREESBORO PIKE
NASHVILLE TN
37217-2432
US

V. Phone/Fax

Practice location:
  • Phone: 615-258-8631
  • Fax:
Mailing address:
  • Phone: 615-258-8631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MARC GOLDSTONE
Title or Position: PC OWNER
Credential:
Phone: 615-551-6325