Healthcare Provider Details

I. General information

NPI: 1215128590
Provider Name (Legal Business Name): CAROLINE CHRISTIAN HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 08/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18048 JEFFERSON DAVIS HWY
RUTHER GLEN VA
22546-2922
US

IV. Provider business mailing address

P.O. BOX 216
LADYSMITH VA
22501-0216
US

V. Phone/Fax

Practice location:
  • Phone: 804-448-1380
  • Fax:
Mailing address:
  • Phone: 804-448-1380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101231223
License Number StateVA

VIII. Authorized Official

Name: MRS. BRANDI GRAHAM
Title or Position: OFFICE MANAGER
Credential:
Phone: 804-448-1380