Provider Demographics
NPI:1659529766
Name:CROZET CHILDRENS HEALTH CENTER PC
Entity Type:Organization
Organization Name:CROZET CHILDRENS HEALTH CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARKETA
Authorized Official - Middle Name:KYNCL
Authorized Official - Last Name:LEISURE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-823-5439
Mailing Address - Street 1:5674 THREE NOTCHED RD
Mailing Address - Street 2:
Mailing Address - City:CROZET
Mailing Address - State:VA
Mailing Address - Zip Code:22932-3109
Mailing Address - Country:US
Mailing Address - Phone:434-823-5439
Mailing Address - Fax:434-823-5453
Practice Address - Street 1:5674 THREE NOTCHED RD
Practice Address - Street 2:
Practice Address - City:CROZET
Practice Address - State:VA
Practice Address - Zip Code:22932-3109
Practice Address - Country:US
Practice Address - Phone:434-823-5439
Practice Address - Fax:434-823-5453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101044383261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care