Healthcare Provider Details

I. General information

NPI: 1326669367
Provider Name (Legal Business Name): SALLY PEACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2020
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9550 MIDLOTHIAN TPKE
NORTH CHESTERFIELD VA
23235-4900
US

IV. Provider business mailing address

9550 MIDLOTHIAN TPKE
NORTH CHESTERFIELD VA
23235-4900
US

V. Phone/Fax

Practice location:
  • Phone: 803-323-4040
  • Fax: 804-323-3787
Mailing address:
  • Phone: 803-323-4040
  • Fax: 804-323-3787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number1202210958
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: