Provider Demographics
NPI:1629019492
Name:FAMILY PRACTICE AT RETREAT LLC
Entity Type:Organization
Organization Name:FAMILY PRACTICE AT RETREAT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-254-9807
Mailing Address - Street 1:110 N ROBINSON ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-4459
Mailing Address - Country:US
Mailing Address - Phone:804-254-9807
Mailing Address - Fax:804-254-9792
Practice Address - Street 1:110 N ROBINSON ST
Practice Address - Street 2:SUITE 203
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-4459
Practice Address - Country:US
Practice Address - Phone:804-254-9807
Practice Address - Fax:804-254-9792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1629019492Medicaid
VA1629019492Medicaid
C09434Medicare PIN