Provider Demographics
NPI:1043662828
Name:CENTRA HEALTH PROFESSIONAL SERVICES, LLC
Entity Type:Organization
Organization Name:CENTRA HEALTH PROFESSIONAL SERVICES, LLC
Other - Org Name:CENTRA HEALTH MEDICAL CENTER-DANVILLE
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:LARKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-200-5047
Mailing Address - Street 1:414 PARK AVENUE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-9998
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:414 PARK AVENUE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-9998
Practice Address - Country:US
Practice Address - Phone:434-791-1562
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRA MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty