Provider Demographics
NPI:1063649515
Name:ACKERMAN, GUY R
Entity Type:Individual
Prefix:
First Name:GUY
Middle Name:R
Last Name:ACKERMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21738 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-2212
Mailing Address - Country:US
Mailing Address - Phone:804-524-9097
Mailing Address - Fax:804-524-9097
Practice Address - Street 1:21738 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-2212
Practice Address - Country:US
Practice Address - Phone:804-524-9097
Practice Address - Fax:804-524-9097
Is Sole Proprietor?:No
Enumeration Date:2009-06-11
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2705089862171W00000X, 171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
No171W00000XOther Service ProvidersContractor