Healthcare Provider Details

I. General information

NPI: 1205239746
Provider Name (Legal Business Name): THOMAS CANTY III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2014
Last Update Date: 09/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CHILDRENS LN
NORFOLK VA
23507-1910
US

IV. Provider business mailing address

5434 HUNT CLUB DR
VIRGINIA BEACH VA
23462-3413
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-7000
  • Fax:
Mailing address:
  • Phone: 804-687-1377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126001256
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: