Healthcare Provider Details

I. General information

NPI: 1821636788
Provider Name (Legal Business Name): ROSCOE CALLAWAY CONTRACTOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2019
Last Update Date: 12/11/2019
Certification Date: 12/11/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 CAMPOSTELLA RD
NORFOLK VA
23523-2103
US

IV. Provider business mailing address

1121 CAMPOSTELLA RD
NORFOLK VA
23523-2103
US

V. Phone/Fax

Practice location:
  • Phone: 757-543-0843
  • Fax: 757-543-0504
Mailing address:
  • Phone: 757-543-0843
  • Fax: 757-543-0504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number2705158786
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: