Healthcare Provider Details

I. General information

NPI: 1457808917
Provider Name (Legal Business Name): MICHAEL ANTWAN BELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

1826 KINGSTON AVE 220
NORFOLK VA
23503-2653
US

IV. Provider business mailing address

1826 KINGSTON AVE. 220
NORFOLK VA
23503-2661
US

V. Phone/Fax

Practice location:
  • Phone: 757-550-5707
  • Fax:
Mailing address:
  • Phone: 757-550-5707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number47-3973441
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: