Healthcare Provider Details

I. General information

NPI: 1417700337
Provider Name (Legal Business Name): MATTHEW BEBLOWSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2024
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 FAIRFAX AVE., SUITE 1017C P.O. BOX 1980
NORFOLK VA
23501
US

IV. Provider business mailing address

735 FAIRFAX AVE., SUITE 1017C P.O. BOX 1980
NORFOLK VA
23501
US

V. Phone/Fax

Practice location:
  • Phone: 757-446-6191
  • Fax: 757-446-6195
Mailing address:
  • Phone: 757-446-6191
  • Fax: 757-446-6195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: