=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164243986
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHAN M PARK FAMILY PRACTICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2024
-----------------------------------------------------
Last Update Date | 11/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6460 GREENSBORO RD
-----------------------------------------------------
City | RIDGEWAY
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24148-3478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-956-2047
-----------------------------------------------------
Fax | 276-956-1637
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6460 GREENSBORO RD
-----------------------------------------------------
City | RIDGEWAY
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24148-3478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-956-2047
-----------------------------------------------------
Fax | 276-956-1637
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | CURTSHER THOBBS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 276-956-2047
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------