Provider Demographics
NPI:1326363417
Name:PENINSULA FAMILY PRACTICE
Entity Type:Organization
Organization Name:PENINSULA FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VALENCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BELLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-826-0020
Mailing Address - Street 1:2115 EXECUTIVE DR
Mailing Address - Street 2:4-C
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-2499
Mailing Address - Country:US
Mailing Address - Phone:757-826-0020
Mailing Address - Fax:
Practice Address - Street 1:2115 EXECUTIVE DR
Practice Address - Street 2:4-C
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2499
Practice Address - Country:US
Practice Address - Phone:757-826-0020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-31
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024000020302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP21653Medicare UPIN