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General NPI Number Information
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NPI Number | 1811582448
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Entity Type | Organization
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Legal Business Name | ELJV LLC
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Dates
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Enumeration Date | 03/05/2021
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Last Update Date | 03/05/2021
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Provider Practice Location Address
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Address Line | 1729 WILDWOOD DR STE 103A
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City | VIRGINIA BEACH
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State | VA
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Zip | 23454-3176
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Country | US
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Telephone | 757-938-3654
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Fax | 757-938-3658
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Provider Business Mailing Address
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Address Line | 1729 WILDWOOD DR STE 103A
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City | VIRGINIA BEACH
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State | VA
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Zip | 23454-3176
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Country | US
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Telephone | 757-938-3654
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Fax | 757-938-3658
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | RUTH ANN WATSON
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Credential |
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Telephone | 757-938-3654
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0401X
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Taxonomy Name | Addiction Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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