Provider Demographics
NPI:1376583047
Name:GEORGALAS, VENISSE A (DC)
Entity Type:Individual
Prefix:DR
First Name:VENISSE
Middle Name:A
Last Name:GEORGALAS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 MIDDLE GROUND BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4525
Mailing Address - Country:US
Mailing Address - Phone:757-591-9390
Mailing Address - Fax:757-873-3861
Practice Address - Street 1:702 A MIDDLE GROUND BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4525
Practice Address - Country:US
Practice Address - Phone:757-591-9390
Practice Address - Fax:757-873-3861
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104000321111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAU51263OtherMEDICARE UPIN