=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013139047
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIRGINIA VASCULAR, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1031 LOFTIS BLVD
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23606-2981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-594-1032
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6015 POPLAR HALL DR STE 308
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23502-3819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-594-1032
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE VICE PRESIDENT
-----------------------------------------------------
Name | KENNETH M KRAKAUR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-594-1031
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------