Healthcare Provider Details

I. General information

NPI: 1942479662
Provider Name (Legal Business Name): SARA BOURAEE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2008
Last Update Date: 03/02/2020
Certification Date: 03/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 PROFESSIONAL DR
WILLIAMSBURG VA
23185-3329
US

IV. Provider business mailing address

1155 PROFESSIONAL DR
WILLIAMSBURG VA
23185-3329
US

V. Phone/Fax

Practice location:
  • Phone: 757-224-7605
  • Fax:
Mailing address:
  • Phone: 757-220-3311
  • Fax: 757-220-9070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number0103301022
License Number StateVA

VIII. Authorized Official

Name: DR. SARA M BOURAEE
Title or Position: OWNER
Credential: DPM
Phone: 757-234-2905