Healthcare Provider Details

I. General information

NPI: 1275381824
Provider Name (Legal Business Name): PRACTITIONERS HEART HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2024
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4760 BISHOPS GATE WAY
PROVIDENCE FORGE VA
23140-4438
US

IV. Provider business mailing address

4760 BISHOPS GATE WAY
PROVIDENCE FORGE VA
23140-4438
US

V. Phone/Fax

Practice location:
  • Phone: 804-661-6519
  • Fax: 904-372-6121
Mailing address:
  • Phone: 804-661-6519
  • Fax: 904-372-6121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. CARLITA T LEWIS
Title or Position: PRACTICE MANAGER
Credential: NP
Phone: 804-661-6519