Healthcare Provider Details

I. General information

NPI: 1487256616
Provider Name (Legal Business Name): ANTIONE LEN CALABRESE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2020
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6426 STONEY PT S
NORFOLK VA
23502-3910
US

IV. Provider business mailing address

6426 STONEY PT S
NORFOLK VA
23502-3910
US

V. Phone/Fax

Practice location:
  • Phone: 757-756-0133
  • Fax:
Mailing address:
  • Phone: 757-756-0133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberT60566521
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: