Healthcare Provider Details

I. General information

NPI: 1275672073
Provider Name (Legal Business Name): CENTER FOR NEUROREHABILITATION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7401 BEAUFONT SPRINGS DR SUITE 205
NORTH CHESTERFIELD VA
23225-5520
US

IV. Provider business mailing address

7401 BEAUFONT SPRINGS DR SUITE 205
NORTH CHESTERFIELD VA
23225-5520
US

V. Phone/Fax

Practice location:
  • Phone: 804-272-0114
  • Fax: 804-272-1125
Mailing address:
  • Phone: 804-272-0114
  • Fax: 804-272-1125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0301X
TaxonomyBrain Injury Medicine (Psychiatry & Neurology) Physician
License Number0101036956
License Number StateVA

VIII. Authorized Official

Name: MR. VAN WILLIAM LUETHKE
Title or Position: ADMINISTRATOR
Credential:
Phone: 804-272-0114