=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093262487
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEAM NURSE II, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2016
-----------------------------------------------------
Last Update Date | 09/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1372 W GRETNA RD STE B
-----------------------------------------------------
City | GRETNA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24557-2472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-656-6000
-----------------------------------------------------
Fax | 434-656-1213
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 776 606 BROAD STREET
-----------------------------------------------------
City | SOUTH BOSTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24592-0776
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-575-5200
-----------------------------------------------------
Fax | 434-575-5054
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF OPERATIONS
-----------------------------------------------------
Name | CHRISTY GLYNN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 434-575-5200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------