=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356612154
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHWEST WOMEN'S HEALTH SERVICES OF VIRGINIA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2012
-----------------------------------------------------
Last Update Date | 01/25/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 127 CALLAHAN AVE
-----------------------------------------------------
City | APPALACHIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24216-1203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-565-2425
-----------------------------------------------------
Fax | 276-565-2427
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10525 EMERSON RD
-----------------------------------------------------
City | WISE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24293-6641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-328-2968
-----------------------------------------------------
Fax | 276-565-2427
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RODOLFO JS CARTAGENA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 276-565-2425
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 0101028013
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------