Provider Demographics
NPI:1487011367
Name:COMMONWEALTH PRIMARY CARE
Entity Type:Organization
Organization Name:COMMONWEALTH PRIMARY CARE
Other - Org Name:COMMONWEALTH EXTENDED CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR/PHYICIAN/SHAREHOLD
Authorized Official - Prefix:DR
Authorized Official - First Name:KARISSA
Authorized Official - Middle Name:L
Authorized Official - Last Name:HACKELTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-285-7425
Mailing Address - Street 1:1800 GLENSIDE DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3769
Mailing Address - Country:US
Mailing Address - Phone:804-285-7425
Mailing Address - Fax:804-673-7074
Practice Address - Street 1:1800 GLENSIDE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-3769
Practice Address - Country:US
Practice Address - Phone:804-285-7425
Practice Address - Fax:804-673-7074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-22
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024172915363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty