MEDICARE: SALUTARIS LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207Q00000X	Family Medicine Physician
2	363L00000X	Nurse Practitioner
3	363LG0600X	Gerontology Nurse Practitioner
4	207QG0300X	Geriatric Medicine (Family Medicine) Physician

General Provider Information

NPI Number	:	1558891887
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SALUTARIS LLC

Provider Business Mailing Address
First Line	:	PO BOX 1191
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23113-8191
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7400 BEAUFONT SPRINGS DR STE 300
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23225-5519
Country	:	US
Telephone Number	:	804-893-3344
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	CLIFTON COFFMAN
Credential	:
Telephone Number	:	804-592-6249

Provider Enumeration Date	:	06/19/2017
Last Update Date	:	06/21/2017

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