Healthcare Provider Details

I. General information

NPI: 1487775896
Provider Name (Legal Business Name): DAVID MELTON DEVERICKS RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8418 VARINA RD
RICHMOND VA
23231-8242
US

IV. Provider business mailing address

8418 VARINA RD
RICHMOND VA
23231-8242
US

V. Phone/Fax

Practice location:
  • Phone: 804-795-2454
  • Fax:
Mailing address:
  • Phone: 804-795-2454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number0001163041
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: