Provider Demographics
NPI:1548411374
Name:GREATHEAD, RONALD (LICAC)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:GREATHEAD
Suffix:
Gender:M
Credentials:LICAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6418
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-6418
Mailing Address - Country:US
Mailing Address - Phone:434-974-7798
Mailing Address - Fax:434-244-2874
Practice Address - Street 1:1108 E MARKET ST
Practice Address - Street 2:SUITE B
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-5351
Practice Address - Country:US
Practice Address - Phone:434-974-7798
Practice Address - Fax:434-244-2874
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000180171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist