Healthcare Provider Details

I. General information

NPI: 1598397374
Provider Name (Legal Business Name): CECIL LINWOOD ALLEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2020
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9430 CHARLES CITY VILLAGE DR
PROVIDENCE FORGE VA
23140-2833
US

IV. Provider business mailing address

9430 CHARLES CITY VILLAGE DR
PROVIDENCE FORGE VA
23140-2833
US

V. Phone/Fax

Practice location:
  • Phone: 908-294-8080
  • Fax:
Mailing address:
  • Phone: 908-294-8080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberA62904660
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: