=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891550786
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAXGIO HEALTHCARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2024
-----------------------------------------------------
Last Update Date | 12/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 411 BRANCHWAY RD STE 109
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23236-3034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-901-0053
-----------------------------------------------------
Fax | 804-509-0514
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 411 BRANCHWAY RD STE 109
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23236-3034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-901-0053
-----------------------------------------------------
Fax | 804-509-0514
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PMHNP
-----------------------------------------------------
Name | ROSE CHIGBO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 701-729-2970
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------