Healthcare Provider Details

I. General information

NPI: 1558688499
Provider Name (Legal Business Name): JACQUELINE M KOWAL R.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2010
Last Update Date: 05/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 NEW KENT HIGHWAY
QUINTON VA
23141
US

IV. Provider business mailing address

2520 NEW KENT HIGHWAY
QUINTON VA
23141
US

V. Phone/Fax

Practice location:
  • Phone: 804-307-4150
  • Fax:
Mailing address:
  • Phone: 804-307-4150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number1101002137
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: