Healthcare Provider Details

I. General information

NPI: 1598860488
Provider Name (Legal Business Name): JDM OF VA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6201 MIDLOTHIAN TPKE
RICHMOND VA
23225-5809
US

IV. Provider business mailing address

7 S ADAMS ST
RICHMOND VA
23220-5601
US

V. Phone/Fax

Practice location:
  • Phone: 804-674-1600
  • Fax: 804-674-1688
Mailing address:
  • Phone: 804-788-1956
  • Fax: 804-788-1940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number52402006
License Number StateVA

VIII. Authorized Official

Name: MR. BERKELEY ANTHONY ALEXANDER
Title or Position: PRESIDENT
Credential: NA
Phone: 804-788-1956