=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538459219
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR ADVANCED LIPID MANAGEMENT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2011
-----------------------------------------------------
Last Update Date | 04/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4806 PLEASANT HILL DR SUITE 201
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24018-3441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-588-7115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38 PEAKS VIEW DR
-----------------------------------------------------
City | MONETA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24121-2566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-588-7115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GEORGE CHACONAS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 540-588-7115
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 0101038267
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------