Healthcare Provider Details

I. General information

NPI: 1699082446
Provider Name (Legal Business Name): OLIVET MEDICAL MINISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2010
Last Update Date: 08/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 OLD WILLIAMSBURG RD
YORKTOWN VA
23690-3910
US

IV. Provider business mailing address

1620 OLD WILLIAMSBURG RD
YORKTOWN VA
23690-3910
US

V. Phone/Fax

Practice location:
  • Phone: 757-886-0608
  • Fax: 757-369-3821
Mailing address:
  • Phone: 757-886-0608
  • Fax: 757-369-3821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number0024164154
License Number StateVA

VIII. Authorized Official

Name: MR. ROBERT BRADLEY JR.
Title or Position: EXECUTIVE DIRECTOR
Credential: SOCIAL WORKER
Phone: 757-886-0608