MEDICARE: MDEVANS LLC

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	251S00000X	Community/Behavioral Health Agency	916149	VA

General Provider Information

NPI Number	:	1265833081
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MDEVANS LLC

Provider Business Mailing Address
First Line	:	5660 E VIRGINIA BEACH BLVD
Second Line	:	SUITE 102
City	:	NORFOLK
State	:	VA
Zip	:	23502-2468
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5660 E VIRGINIA BEACH BLVD
Second Line	:	SUITE 102
City	:	NORFOLK
State	:	VA
Zip	:	23502-2468
Country	:	US
Telephone Number	:	757-469-9604
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MRS. FIATA D JONES
Credential	:
Telephone Number	:	757-496-9604

Provider Enumeration Date	:	09/11/2014
Last Update Date	:	09/11/2014

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