Healthcare Provider Details

I. General information

NPI: 1184252520
Provider Name (Legal Business Name): CARLYN GRACE VAN BLARICUM DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 03/31/2020
Certification Date: 03/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 MCLAWS CIR
WILLIAMSBURG VA
23185-5649
US

IV. Provider business mailing address

902 CONWAY DR APT 204
WILLIAMSBURG VA
23185-3838
US

V. Phone/Fax

Practice location:
  • Phone: 757-259-1122
  • Fax:
Mailing address:
  • Phone: 913-568-1556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104-557635
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: