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General NPI Number Information
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NPI Number | 1790204196
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Entity Type | Organization
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Legal Business Name | VIRGINIA LICE REMOVAL, LLC
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Dates
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Enumeration Date | 09/17/2017
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Last Update Date | 09/17/2017
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Provider Practice Location Address
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Address Line | 1901 HUGUENOT RD STE 101
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23235-4311
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Country | US
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Telephone | 804-337-3124
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Fax | 804-337-3124
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Provider Business Mailing Address
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Address Line | 12605 SOUTHWICK TER
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City | MIDLOTHIAN
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State | VA
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Zip | 23113-2848
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Country | US
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Telephone | 804-387-6509
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. GERARD PHILLIP WOLBURG
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Credential |
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Telephone | 804-387-6509
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 247200000X
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Taxonomy Name | Other Technician
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License Number |
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License Number State |
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