Healthcare Provider Details

I. General information

NPI: 1326093139
Provider Name (Legal Business Name): REBECCA MCCORMACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 12/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12715 WARWICK BLVD SUITE V
NEWPORT NEWS VA
23606-1800
US

IV. Provider business mailing address

12715 WARWICK BLVD SUITE V
NEWPORT NEWS VA
23606-1800
US

V. Phone/Fax

Practice location:
  • Phone: 757-930-0139
  • Fax: 757-930-4132
Mailing address:
  • Phone: 757-930-0139
  • Fax: 757-930-4132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number186930 2006
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: