=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235312208
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIRGINIA WELLNESS ASSOCIATES NORFOLK, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2007
-----------------------------------------------------
Last Update Date | 12/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 738 W 22ND ST SUITE 5
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23517-1983
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-627-2222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6804 PATTERSON AVE
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23226-3429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-285-4201
-----------------------------------------------------
Fax | 804-285-4202
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CHARLES HUNTER REYNOLDS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-285-4201
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------