=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124251491
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEACHTOWN HEALTH CARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2009
-----------------------------------------------------
Last Update Date | 07/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3750 CHESTERFIELD AVE
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23455-2940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-460-7189
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3750 CHESTERFIELD AVE
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23455-2940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-460-7189
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RAYMOND IGLECIA JR.
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 757-460-7189
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 0101057390
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 0101057390
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------