Healthcare Provider Details

I. General information

NPI: 1457652042
Provider Name (Legal Business Name): VIRGIN ISLANDS IV
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2010
Last Update Date: 11/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2024 EST. MT. WELCOME SUITE #12
CHRISTIANSTED VI
00820
US

IV. Provider business mailing address

2024 EST. MT. WELCOME SUITE #12
CHRISTIANSTED VI
00820
US

V. Phone/Fax

Practice location:
  • Phone: 340-719-8448
  • Fax: 340-719-8484
Mailing address:
  • Phone: 340-719-8448
  • Fax: 340-719-8484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number5009518
License Number StateVI

VIII. Authorized Official

Name: RODNEY GORDON
Title or Position: PRESIDENT/COO
Credential:
Phone: 340-513-4703