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General NPI Number Information
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NPI Number | 1366834749
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Entity Type | Organization
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Legal Business Name | CHESAPEAKE BAY ENT
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Dates
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Enumeration Date | 02/23/2015
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Last Update Date | 02/23/2015
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Provider Practice Location Address
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Address Line | 1232 PERIMETER PKWY SUITE 104
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City | VIRGINIA BEACH
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State | VA
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Zip | 23454-5924
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Country | US
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Telephone | 757-821-2090
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Fax | 757-821-2091
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Provider Business Mailing Address
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Address Line | PO BOX 68279
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City | VIRGINIA BEACH
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State | VA
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Zip | 23471-8279
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Country | US
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Telephone | 757-821-2090
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Fax | 757-821-2091
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Authorized Official
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Title or Position | REGIONAL PRACTICE ADMINISTRATOR
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Name | MRS. DETRA RENEE SAFFOLD
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Credential |
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Telephone | 757-821-2090
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 0110001371
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License Number State | VA
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