=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487664264
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRACY M. HERNANDEZ, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2224 VIRGINIA BEACH BLVD SUITE 106
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23454-4285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-486-8663
-----------------------------------------------------
Fax | 757-486-2650
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2224 VIRGINIA BEACH BLVD SUITE 106
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23454-4285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TRACY M. HERNANDEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-486-8663
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------