Healthcare Provider Details

I. General information

NPI: 1205443876
Provider Name (Legal Business Name): BEACH SURGICAL ASSISTANTS OF VA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2020
Last Update Date: 11/11/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2233 ELDER RD
VIRGINIA BEACH VA
23451-1105
US

IV. Provider business mailing address

2233 ELDER RD
VIRGINIA BEACH VA
23451-1105
US

V. Phone/Fax

Practice location:
  • Phone: 757-343-4735
  • Fax:
Mailing address:
  • Phone: 757-343-4735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MRS. DEBORAH REDMOND
Title or Position: SURGICAL ASSISTANT, OWNER
Credential: CSA
Phone: 757-343-4735