Healthcare Provider Details

I. General information

NPI: 1477214740
Provider Name (Legal Business Name): JUANITO SANTOS DUALAN JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2022
Last Update Date: 01/08/2022
Certification Date: 01/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1792 MOONSTONE DR
VIRGINIA BEACH VA
23456-5861
US

IV. Provider business mailing address

1792 MOONSTONE DR
VIRGINIA BEACH VA
23456-5861
US

V. Phone/Fax

Practice location:
  • Phone: 757-971-0323
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number0117007087
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: