Healthcare Provider Details

I. General information

NPI: 1427218726
Provider Name (Legal Business Name): PERCIVAL VALENZUELA IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2008
Last Update Date: 06/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1865 COVE RD BLDG 3806
NORFOLK VA
23521-2911
US

IV. Provider business mailing address

1865 COVE RD BLDG 3806
NORFOLK VA
23521-2911
US

V. Phone/Fax

Practice location:
  • Phone: 757-462-3780
  • Fax: 757-462-4825
Mailing address:
  • Phone: 757-462-3780
  • Fax: 757-462-4825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberB1505257
License Number StateZZ
# 2
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: