Healthcare Provider Details

I. General information

NPI: 1992960272
Provider Name (Legal Business Name): JEREMY ACEBEDO LLAVORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2008
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4035 ELECTRIC RD STE B
ROANOKE VA
24018-8449
US

IV. Provider business mailing address

4035 ELECTRIC RD STE B
ROANOKE VA
24018-8449
US

V. Phone/Fax

Practice location:
  • Phone: 540-767-0380
  • Fax: 540-772-2370
Mailing address:
  • Phone: 540-767-0380
  • Fax: 540-772-2370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number116020100
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: