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General NPI Number Information
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NPI Number | 1265851836
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Entity Type | Organization
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Legal Business Name | COMMONWEALTH CARE SERVICES LLC
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Dates
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Enumeration Date | 04/10/2014
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Last Update Date | 04/10/2014
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Provider Practice Location Address
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Address Line | 444 PINE RIDGE RD
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City | PETERSBURG
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State | VA
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Zip | 23805-1320
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Country | US
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Telephone | 804-919-1126
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Fax |
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Provider Business Mailing Address
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Address Line | 444 PINE RIDGE RD
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City | PETERSBURG
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State | VA
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Zip | 23805-1320
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Country | US
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Telephone | 804-919-1126
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JOVAT C BATES
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Credential |
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Telephone | 804-919-1126
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | 2059-010001
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License Number State | VA
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