Healthcare Provider Details

I. General information

NPI: 1366944670
Provider Name (Legal Business Name): VALLEY PHYSICIAN ENTERPRISE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2018
Last Update Date: 12/17/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1880 AMHERST STREET
WINCHESTER VA
22601
US

IV. Provider business mailing address

220 CAMPUS BLVD STE 100
WINCHESTER VA
22601-2888
US

V. Phone/Fax

Practice location:
  • Phone: 540-662-0306
  • Fax: 855-264-2066
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateVA

VIII. Authorized Official

Name: RENEE NEVADA JOHNSON
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 540-536-0103