Provider Demographics
NPI:1407021934
Name:MACGREGOR ENTERPRISES LLC
Entity Type:Organization
Organization Name:MACGREGOR ENTERPRISES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:TILLAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-594-9005
Mailing Address - Street 1:703 THIMBLE SHOALS BLVD
Mailing Address - Street 2:SUITE C-3
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-2576
Mailing Address - Country:US
Mailing Address - Phone:757-594-9005
Mailing Address - Fax:757-594-9215
Practice Address - Street 1:703 THIMBLE SHOALS BLVD
Practice Address - Street 2:SUITE C-3
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-2576
Practice Address - Country:US
Practice Address - Phone:757-594-9005
Practice Address - Fax:757-594-9215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401005891122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1245250927Medicaid