=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467565804
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOUNTAIN REGION FAMILY MEDICINE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2006
-----------------------------------------------------
Last Update Date | 12/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 142 MEADE AVENUE
-----------------------------------------------------
City | NICKELSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-479-2201
-----------------------------------------------------
Fax | 276-479-3314
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 142 MEADE AVENUE
-----------------------------------------------------
City | NICKELSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-479-2201
-----------------------------------------------------
Fax | 276-479-3314
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CORPORATE SECRETARY
-----------------------------------------------------
Name | WANDA Y TRENT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 423-224-3400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------