MEDICARE: CHRISTINA SOUTHERS MASTERS BOARD CERT.

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	246ZA2600X	Medical Art Specialist/Technologist		VA

General Provider Information

NPI Number	:	1255047270
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINA SOUTHERS MASTERS BOARD CERT.

Provider Business Mailing Address
First Line	:	3511 BELLBLUFF DR
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23237-1002
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	587 SOUTHLAKE BLVD STE A
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23236-3096
Country	:	US
Telephone Number	:	804-895-7616
Fax Number	:

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

Provider Enumeration Date	:	01/24/2023
Last Update Date	:	02/01/2023

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