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General NPI Number Information
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NPI Number | 1982051876
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Entity Type | Individual
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Provider Name | MR. LOUIS JOLLEY
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Gender | Male
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Dates
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Enumeration Date | 05/20/2016
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Last Update Date | 05/20/2016
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Provider Practice Location Address
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Address Line | 16040 IMPERIAL EAGLE CT
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City | WOODBRIDGE
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State | VA
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Zip | 22191-6559
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Country | US
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Telephone | 678-542-5003
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Fax |
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Provider Business Mailing Address
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Address Line | 16040 IMPERIAL EAGLE COURT
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City | WODBRIDGE
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State | VA
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Zip | 22191
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Country | US
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Telephone | 678-542-5003
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 172A00000X
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Taxonomy Name | Driver
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License Number | D06287776
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License Number State | AZ
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