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General NPI Number Information
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NPI Number | 1205159423
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Entity Type | Organization
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Legal Business Name | CHESAPEAKE HYPERBARIC LC
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Dates
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Enumeration Date | 03/02/2010
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Last Update Date | 03/02/2010
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Provider Practice Location Address
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Address Line | 129 SEAGROVE MAIN STREET UNIT 202
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City | ST. AUGUSTINE
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State | FL
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Zip | 32080
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Country | US
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Telephone | 804-296-4094
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Fax |
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Provider Business Mailing Address
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Address Line | 9562 DEERECO ROAD
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City | UTHERVILLE
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State | MD
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Zip | 21093
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Country | US
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Telephone | 904-271-1053
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. MICHELLE RENEE REILLO
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Credential | PH.D., R.N.
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Telephone | 904-271-1053
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | R080304
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License Number State | MD
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