Provider Demographics
NPI:1609073485
Name:COMMONWEALTH CLINIC
Entity Type:Organization
Organization Name:COMMONWEALTH CLINIC
Other - Org Name:LOVE OF JESUS HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PAWLAK
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:804-674-7499
Mailing Address - Street 1:10930 HULL STREET RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-3316
Mailing Address - Country:US
Mailing Address - Phone:804-674-7499
Mailing Address - Fax:804-674-7448
Practice Address - Street 1:10930 HULL STREET RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3316
Practice Address - Country:US
Practice Address - Phone:804-674-7499
Practice Address - Fax:804-674-7448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2007-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center