Healthcare Provider Details

I. General information

NPI: 1114667110
Provider Name (Legal Business Name): MIZELLORE MEDICAL SOLUTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2022
Last Update Date: 03/30/2022
Certification Date: 03/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3755 WILMONT AVE NW
ROANOKE VA
24017-6509
US

IV. Provider business mailing address

4727 VALLEY VIEW BLVD NW # 1061
ROANOKE VA
24012-2000
US

V. Phone/Fax

Practice location:
  • Phone: 540-494-4457
  • Fax:
Mailing address:
  • Phone: 540-494-4457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MIZELLORE LEXIMA
Title or Position: OWNER
Credential: RN
Phone: 540-494-4457