MEDICARE: DONNELL FONVILLE

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	267	VA

General Provider Information

NPI Number	:	1467808923
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNELL FONVILLE

Provider Business Mailing Address
First Line	:	4137 WOODFIELD RD
Second Line	:
City	:	N CHESTERFIELD
State	:	VA
Zip	:	23234
Country	:	US
Telephone Number	:	804-229-5353
Fax Number	:	804-859-7921

Provider Business Practice Location Address
First Line	:	4137 WOODFIELD RD
Second Line	:
City	:	N CHESTERFIELD
State	:	VA
Zip	:	23234
Country	:	US
Telephone Number	:	804-229-5353
Fax Number	:	804-859-7921

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

Provider Enumeration Date	:	05/13/2016
Last Update Date	:	05/13/2016

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Directions to “ DONNELL FONVILLE ” Practice Location

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