Healthcare Provider Details

I. General information

NPI: 1386371888
Provider Name (Legal Business Name): CHRIS GOLLUB
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3945 DOE RUN RD
NORTH PRINCE GEORGE VA
23860-8771
US

IV. Provider business mailing address

1030 FLORIDA AVE
LYNCHBURG VA
24504-4809
US

V. Phone/Fax

Practice location:
  • Phone: 804-898-5946
  • Fax:
Mailing address:
  • Phone: 804-898-5946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: