=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306941505
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILDREN'S CLINIC LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2006
-----------------------------------------------------
Last Update Date | 08/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23 MANHATTAN SQUARE
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-595-0358
-----------------------------------------------------
Fax | 757-595-6745
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23 MANHATTAN SQUARE
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-595-0358
-----------------------------------------------------
Fax | 757-595-6745
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JULIAN H BLALOCK JR JR.
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 757-595-0358
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 0101035213
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------