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General NPI Number Information
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NPI Number | 1265833081
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Entity Type | Organization
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Legal Business Name | MDEVANS LLC
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Dates
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Enumeration Date | 09/11/2014
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Last Update Date | 09/11/2014
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Provider Practice Location Address
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Address Line | 5660 E VIRGINIA BEACH BLVD SUITE 102
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City | NORFOLK
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State | VA
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Zip | 23502-2468
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Country | US
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Telephone | 757-469-9604
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Fax |
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Provider Business Mailing Address
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Address Line | 5660 E VIRGINIA BEACH BLVD SUITE 102
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City | NORFOLK
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State | VA
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Zip | 23502-2468
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MRS. FIATA D JONES
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Credential |
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Telephone | 757-496-9604
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 916149
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License Number State | VA
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