Healthcare Provider Details

I. General information

NPI: 1417390048
Provider Name (Legal Business Name): CJW SPORTS MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2013
Last Update Date: 04/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1457 JOHNSTON WILLIS DR
NORTH CHESTERFIELD VA
23235-4730
US

IV. Provider business mailing address

1115 BOULDERS PKWY SUITE 110
NORTH CHESTERFIELD VA
23225-4067
US

V. Phone/Fax

Practice location:
  • Phone: 804-560-6500
  • Fax: 804-560-6505
Mailing address:
  • Phone: 804-560-6511
  • Fax: 804-560-6505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. HUNTER LEE DURVIN
Title or Position: PRACTICE MANAGER
Credential: ATC
Phone: 804-560-6511