Healthcare Provider Details

I. General information

NPI: 1891020525
Provider Name (Legal Business Name): ELENA MUDEN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2009
Last Update Date: 10/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3514 MAYLAND CT
RICHMOND VA
23233-1421
US

IV. Provider business mailing address

PO BOX 5820
GLEN ALLEN VA
23058-5820
US

V. Phone/Fax

Practice location:
  • Phone: 804-747-0003
  • Fax: 804-747-0043
Mailing address:
  • Phone: 804-747-0003
  • Fax: 804-747-0043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2305204549
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: