Healthcare Provider Details

I. General information

NPI: 1639443922
Provider Name (Legal Business Name): JEFF CARROLL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2012
Last Update Date: 03/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CARROLL LN
PAMPLIN VA
23958-2145
US

IV. Provider business mailing address

200 CARROLL LN
PAMPLIN VA
23958-2145
US

V. Phone/Fax

Practice location:
  • Phone: 434-248-6910
  • Fax: 434-248-6910
Mailing address:
  • Phone: 434-248-6910
  • Fax: 434-248-6910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number2705 108547A
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: