1639448962 NPI number — CHIPPENHAM & JOHNSTON WILLIS SPORTS MEDICINE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639448962 NPI number — CHIPPENHAM & JOHNSTON WILLIS SPORTS MEDICINE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHIPPENHAM & JOHNSTON WILLIS SPORTS MEDICINE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639448962
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1115 BOULDERS PKWY
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
NORTH CHESTERFIELD
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23225-4067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-560-6500
Provider Business Mailing Address Fax Number:
804-560-6505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1115 BOULDERS PKWY
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
NORTH CHESTERFIELD
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23225-4067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-560-6500
Provider Business Practice Location Address Fax Number:
804-560-6505
Provider Enumeration Date:
12/15/2011

Additional Information

Authorized Official

Authorized Official Last Name:
DURVIN
Authorized Official First Name:
HUNTER
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
804-560-6511

Provider Taxonomy Codes

  • Taxonomy code: 207QS0010X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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