=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629019492
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY PRACTICE AT RETREAT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2006
-----------------------------------------------------
Last Update Date | 01/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 N ROBINSON ST SUITE 203
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23220-4459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-254-9807
-----------------------------------------------------
Fax | 804-254-9792
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 N ROBINSON ST SUITE 203
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23220-4459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-254-9807
-----------------------------------------------------
Fax | 804-254-9792
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP
-----------------------------------------------------
Name | CAROL SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-254-9807
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------