Provider Demographics
NPI:1417390048
Name:CJW SPORTS MEDICINE, LLC
Entity Type:Organization
Organization Name:CJW SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:HUNTER
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DURVIN
Authorized Official - Suffix:
Authorized Official - Credentials:ATC
Authorized Official - Phone:804-560-6511
Mailing Address - Street 1:1115 BOULDERS PKWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4067
Mailing Address - Country:US
Mailing Address - Phone:804-560-6511
Mailing Address - Fax:804-560-6505
Practice Address - Street 1:1457 JOHNSTON WILLIS DR
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-4730
Practice Address - Country:US
Practice Address - Phone:804-560-6500
Practice Address - Fax:804-560-6505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-13
Last Update Date:2013-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACO9544Medicare UPIN