Healthcare Provider Details

I. General information

NPI: 1124251491
Provider Name (Legal Business Name): BEACHTOWN HEALTH CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2009
Last Update Date: 07/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3750 CHESTERFIELD AVE
VIRGINIA BEACH VA
23455-2940
US

IV. Provider business mailing address

3750 CHESTERFIELD AVE
VIRGINIA BEACH VA
23455-2940
US

V. Phone/Fax

Practice location:
  • Phone: 757-460-7189
  • Fax:
Mailing address:
  • Phone: 757-460-7189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101057390
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101057390
License Number StateVA

VIII. Authorized Official

Name: DR. RAYMOND IGLECIA JR.
Title or Position: OWNER
Credential: M.D.
Phone: 757-460-7189