Provider Demographics
NPI:1508286725
Name:RETRO MEDICAL LLC
Entity Type:Organization
Organization Name:RETRO MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:FELLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:757-348-4736
Mailing Address - Street 1:5241 BALBOA DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-2641
Mailing Address - Country:US
Mailing Address - Phone:757-348-4736
Mailing Address - Fax:757-279-7090
Practice Address - Street 1:5241 BALBOA DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-2641
Practice Address - Country:US
Practice Address - Phone:757-348-4736
Practice Address - Fax:757-279-7090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-27
Last Update Date:2014-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166865363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1316982457OtherINDIVIDUAL NPI FOR DR JENNIFER FELLMAN