=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447614920
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MODERN RICHMOND ENDOCRINOLOGY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2016
-----------------------------------------------------
Last Update Date | 06/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1467 JOHNSTON WILLIS DR
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23235-4730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-267-6920
-----------------------------------------------------
Fax | 804-267-6921
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1467 JOHNSTON WILLIS DR
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23235-4730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-267-6920
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LEANZA LIU
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 804-267-6920
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | 0101247055
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------