Healthcare Provider Details

I. General information

NPI: 1518157957
Provider Name (Legal Business Name): SPECIALTY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 08/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18688 JEB STUART HWY
STUART VA
24171-1559
US

IV. Provider business mailing address

18688 JEB STUART HWY
STUART VA
24171-1559
US

V. Phone/Fax

Practice location:
  • Phone: 276-694-3151
  • Fax: 276-694-8655
Mailing address:
  • Phone: 276-694-3151
  • Fax: 276-694-8655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JANICE F WILKINS
Title or Position: ADMINISTRATOR
Credential:
Phone: 276-694-8678