Healthcare Provider Details

I. General information

NPI: 1972714079
Provider Name (Legal Business Name): MILAN LASSITER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 01/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 WEST MAIN STREET
RICHMOND VA
23220
US

IV. Provider business mailing address

1303 WEST MAIN STREET
RICHMOND VA
23220
US

V. Phone/Fax

Practice location:
  • Phone: 804-254-5765
  • Fax: 804-254-5763
Mailing address:
  • Phone: 804-254-5765
  • Fax: 804-254-5763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number0104-555801
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104-555801
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: