Healthcare Provider Details

I. General information

NPI: 1396757357
Provider Name (Legal Business Name): EJL DCH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 TURKEYSAG TRL SUITE 5
PALMYRA VA
22963-2656
US

IV. Provider business mailing address

202 TURKEYSAG TRL SUITE 5
PALMYRA VA
22963-2656
US

V. Phone/Fax

Practice location:
  • Phone: 434-591-0900
  • Fax: 866-836-8883
Mailing address:
  • Phone: 434-591-0900
  • Fax: 866-836-8883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104001713
License Number StateVA

VIII. Authorized Official

Name: DR. EDWARD J LAUTERBACH
Title or Position: PRESIDENT
Credential: D.C.
Phone: 434-591-0900