Provider Demographics
NPI:1659885945
Name:R. VALENTINE, JR., LLC
Entity Type:Organization
Organization Name:R. VALENTINE, JR., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:N
Authorized Official - Last Name:VALENTINE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:757-473-2021
Mailing Address - Street 1:700 INDEPENDENCE CIR STE 2A
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-6405
Mailing Address - Country:US
Mailing Address - Phone:757-473-2021
Mailing Address - Fax:888-408-2550
Practice Address - Street 1:700 INDEPENDENCE CIR STE 2A
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-6405
Practice Address - Country:US
Practice Address - Phone:757-473-2021
Practice Address - Fax:888-408-2550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-22
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAVA0101031884174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6259456Medicaid