Healthcare Provider Details

I. General information

NPI: 1912454265
Provider Name (Legal Business Name): MR. IVAN TOLBERT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2016
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 DAKOTA AVE
RICHMOND VA
23220-6911
US

IV. Provider business mailing address

PO BOX 7258
RICHMOND VA
23221-0258
US

V. Phone/Fax

Practice location:
  • Phone: 804-477-7447
  • Fax:
Mailing address:
  • Phone: 804-418-0876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: