=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609521558
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BENEVOLENT HEALTHCARE SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2022
-----------------------------------------------------
Last Update Date | 01/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1769 JAMESTOWN RD STE 101
-----------------------------------------------------
City | WILLIAMSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23185-2310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-719-9039
-----------------------------------------------------
Fax | 866-432-1706
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2212 FLOWERDEW CT
-----------------------------------------------------
City | WILLIAMSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23185-3190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-850-8636
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE ADMINISTRATOR
-----------------------------------------------------
Name | PEGGY JANE RIDENOUR-WOLFE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 859-221-8587
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171400000X
-----------------------------------------------------
Taxonomy Name | Health & Wellness Coach
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------