Provider Demographics
NPI:1629699913
Name:DECORUM HEALTH SERVICES
Entity Type:Organization
Organization Name:DECORUM HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:ZIKES
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:540-392-3699
Mailing Address - Street 1:PO BOX 31494
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23294-1494
Mailing Address - Country:US
Mailing Address - Phone:540-392-3699
Mailing Address - Fax:
Practice Address - Street 1:3615 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-1961
Practice Address - Country:US
Practice Address - Phone:540-378-9772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024172938OtherMEDICAL LICENSE VIRGINIA
VAMZ3658917OtherDEA