MEDICARE: MORNING STAR FAMILY MEDICINE PC

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	291U00000X	Clinical Medical Laboratory	49D0965836	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588621650
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MORNING STAR FAMILY MEDICINE PC

Provider Business Mailing Address
First Line	:	109 DEER RUN RD
Second Line	:
City	:	DANVILLE
State	:	VA
Zip	:	24540-2863
Country	:	US
Telephone Number	:	434-791-0306
Fax Number	:	434-791-0310

Provider Business Practice Location Address
First Line	:	109 DEER RUN RD
Second Line	:
City	:	DANVILLE
State	:	VA
Zip	:	24540-2863
Country	:	US
Telephone Number	:	434-791-0306
Fax Number	:	434-791-0310

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. EDWIN FUENTES
Credential	:	D.O.
Telephone Number	:	434-791-0306

Provider Enumeration Date	:	05/01/2006
Last Update Date	:	11/30/2015

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