Healthcare Provider Details

I. General information

NPI: 1104052422
Provider Name (Legal Business Name): CHAD NATHAN ROBERTS SUBMARINE IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2009
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 JOHN PAUL JONES CIR
PORTSMOUTH VA
23708-2111
US

IV. Provider business mailing address

741 HARRIS POINT DR
VIRGINIA BEACH VA
23455
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-2032
  • Fax:
Mailing address:
  • Phone: 757-708-8591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number0001253773
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: