Healthcare Provider Details

I. General information

NPI: 1396728317
Provider Name (Legal Business Name): JEFFERSON KIRKLAND TEASS DC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 VIRGINIA AVE
VINTON VA
24179
US

IV. Provider business mailing address

PO BOX 646 300 VIRGINIA AVE
VINTON VA
24179-0646
US

V. Phone/Fax

Practice location:
  • Phone: 540-982-2920
  • Fax: 540-342-4835
Mailing address:
  • Phone: 540-982-2920
  • Fax: 540-342-4835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104000446
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: