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General NPI Number Information
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NPI Number | 1043002934
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Entity Type | Organization
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Legal Business Name | EASTLAKE PRIMARY CARE PC
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Dates
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Enumeration Date | 05/19/2025
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Last Update Date | 10/29/2025
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Provider Practice Location Address
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Address Line | 14807 MONETA RD STE J
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City | MONETA
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State | VA
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Zip | 24121-6449
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Country | US
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Telephone | 540-703-2682
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Fax |
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Provider Business Mailing Address
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Address Line | 14807 MONETA RD STE J
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City | MONETA
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State | VA
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Zip | 24121-6449
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Country | US
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Telephone | 540-703-2682
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MRS. HOLLY HULLETT ROY
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Credential | PA-C
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Telephone | 540-703-2682
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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