MEDICARE: MR. LORENZO JERMAINE BUNCH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver	T62673404	VA

General Provider Information

NPI Number	:	1093680464
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LORENZO JERMAINE BUNCH

Provider Business Mailing Address
First Line	:	6702 BURBAGE LANDING CIR
Second Line	:
City	:	SUFFOLK
State	:	VA
Zip	:	23435-3080
Country	:	US
Telephone Number	:	757-813-4819
Fax Number	:	757-813-4819

Provider Business Practice Location Address
First Line	:	4605 PEMBROKE LAKE CIR STE 202
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-6436
Country	:	US
Telephone Number	:	757-813-4819
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/07/2025
Last Update Date	:	10/07/2025

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