Healthcare Provider Details

I. General information

NPI: 1386716264
Provider Name (Legal Business Name): DOUGLAS F AMBROSE DC, FIAMA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 02/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 SOUTHLAKE BLVD
NORTH CHESTERFIELD VA
23236-3042
US

IV. Provider business mailing address

535 SOUTHLAKE BLVD
RICHMOND VA
23236-3042
US

V. Phone/Fax

Practice location:
  • Phone: 804-897-6130
  • Fax: 804-924-2168
Mailing address:
  • Phone: 804-897-6130
  • Fax: 804-897-6130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0900X
TaxonomyInternist Chiropractor
License Number0104001902
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: