Healthcare Provider Details

I. General information

NPI: 1891871224
Provider Name (Legal Business Name): KING & QUEEN FAMILY PRACTICE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 06/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 SMITHFIELD ROAD
ST STEPHNS CH VA
23148-0130
US

IV. Provider business mailing address

PO BOX 130
ST STEPHNS CH VA
23148-0130
US

V. Phone/Fax

Practice location:
  • Phone: 804-769-0103
  • Fax: 804-769-0508
Mailing address:
  • Phone: 804-769-0103
  • Fax: 804-769-0508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. WILLIAM B GWATHMY
Title or Position: ADMINISTRATOR
Credential: MD
Phone: 804-769-0103