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General NPI Number Information
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NPI Number | 1295914679
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Entity Type | Organization
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Legal Business Name | CLINCH VALLEY NEPHROLOGY,INC.
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Dates
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Enumeration Date | 11/01/2007
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Last Update Date | 11/01/2007
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Provider Practice Location Address
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Address Line | 2951 FRONT ST CLINCH VALLEY MEDICAL PLAZA, SUITE 1600
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City | RICHLANDS
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State | VA
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Zip | 24641-2055
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Country | US
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Telephone | 276-964-4001
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Fax |
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Provider Business Mailing Address
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Address Line | 2951 FRONT ST CLINCH VALLEY MEDICAL PLAZA, SUITE 1600
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City | RICHLANDS
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State | VA
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Zip | 24641-2055
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Country | US
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Telephone | 276-964-4001
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Fax |
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Authorized Official
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Title or Position | C.E.O.
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Name | IN YOUNG PARK
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Credential | M.D.
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Telephone | 276-964-4001
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number | 0101029175
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License Number State | VA
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