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General NPI Number Information
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NPI Number | 1497106504
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Entity Type | Organization
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Legal Business Name | CENTERCARE FAMILY PRACTICE, LLC
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Dates
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Enumeration Date | 06/29/2016
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Last Update Date | 12/30/2022
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Provider Practice Location Address
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Address Line | 1300 EMANCIPATION HWY
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City | FREDERICKSBURG
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State | VA
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Zip | 22401-4600
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Country | US
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Telephone | 540-289-2273
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Fax | 540-699-0214
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Provider Business Mailing Address
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Address Line | 1010 W KENSINGTON CIR
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City | FREDERICKSBURG
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State | VA
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Zip | 22401-8003
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Country | US
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Telephone | 239-691-5450
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MICKELINA LAURORE
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Credential | FNP
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Telephone | 239-691-5450
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State | VA
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