Healthcare Provider Details

I. General information

NPI: 1407815392
Provider Name (Legal Business Name): ERIC LANDRY PROVO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 10/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8857 1ST ST STE 400
NORFOLK VA
23511-3713
US

IV. Provider business mailing address

8857 1ST ST STE 400
NORFOLK VA
23511-3713
US

V. Phone/Fax

Practice location:
  • Phone: 757-445-7256
  • Fax: 757-576-4161
Mailing address:
  • Phone: 757-445-7256
  • Fax: 757-576-4161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: