Healthcare Provider Details

I. General information

NPI: 1629699913
Provider Name (Legal Business Name): DECORUM HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2020
Last Update Date: 03/07/2023
Certification Date: 04/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3615 W MAIN ST
SALEM VA
24153-1961
US

IV. Provider business mailing address

PO BOX 31494
HENRICO VA
23294-1494
US

V. Phone/Fax

Practice location:
  • Phone: 540-378-9772
  • Fax:
Mailing address:
  • Phone: 540-392-3699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TRACY L ZIKES
Title or Position: AUTHORIZED OFFICIAL PRESIDENT
Credential: NP
Phone: 540-392-3699