Provider Demographics
NPI:1144744780
Name:BASKERVILLE, GEORGICA RYNESHA
Entity Type:Individual
Prefix:
First Name:GEORGICA
Middle Name:RYNESHA
Last Name:BASKERVILLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2683 BRODNAX RD
Mailing Address - Street 2:
Mailing Address - City:BRODNAX
Mailing Address - State:VA
Mailing Address - Zip Code:23920-2821
Mailing Address - Country:US
Mailing Address - Phone:434-247-1562
Mailing Address - Fax:434-636-5831
Practice Address - Street 1:2683 BRODNAX RD
Practice Address - Street 2:
Practice Address - City:BRODNAX
Practice Address - State:VA
Practice Address - Zip Code:23920-2821
Practice Address - Country:US
Practice Address - Phone:434-247-1562
Practice Address - Fax:434-636-5831
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty