Healthcare Provider Details

I. General information

NPI: 1083876403
Provider Name (Legal Business Name): SUPPORT SYSTEMS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 HARDY RD
VINTON VA
24179-3526
US

IV. Provider business mailing address

519 HARDY RD
VINTON VA
24179-3526
US

V. Phone/Fax

Practice location:
  • Phone: 540-293-4400
  • Fax: 540-767-7669
Mailing address:
  • Phone: 540-293-4400
  • Fax: 540-767-7669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number1225-03-001
License Number StateVA

VIII. Authorized Official

Name: JENNIFER D GOBBLE
Title or Position: OWNER/DIRECTOR
Credential: LMHP
Phone: 540-293-4400