Provider Demographics
NPI:1164720058
Name:CENTRA MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:CENTRA MEDICAL GROUP, LLC
Other - Org Name:ALTAVISTA MEDICAL CENTER RHC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP, CFO
Authorized Official - Prefix:
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ADDISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-200-3656
Mailing Address - Street 1:1204 FENWICK DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-2112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1280A MAIN ST
Practice Address - Street 2:
Practice Address - City:ALTAVISTA
Practice Address - State:VA
Practice Address - Zip Code:24517-1465
Practice Address - Country:US
Practice Address - Phone:434-309-1165
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRA MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-02
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
C09704Medicare PIN