MEDICARE: NP GERIATRIC ADULT CARE 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	363LG0600X	Gerontology Nurse Practitioner	0024175955	VA

General Provider Information

NPI Number	:	1336636265
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NP GERIATRIC ADULT CARE LLC

Provider Business Mailing Address
First Line	:	1048 TERRACE DR
Second Line	:
City	:	MARION
State	:	VA
Zip	:	24354-4138
Country	:	US
Telephone Number	:	276-783-1827
Fax Number	:	276-783-2879

Provider Business Practice Location Address
First Line	:	500 CLINIC DR
Second Line	:
City	:	CEDAR BLUFF
State	:	VA
Zip	:	24609-9406
Country	:	US
Telephone Number	:	276-596-9750
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TERESA C PENNINGTON
Credential	:	AGPCNP-BC
Telephone Number	:	276-759-8825

Provider Enumeration Date	:	04/17/2018
Last Update Date	:	04/27/2018

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