Provider Demographics
NPI:1689096778
Name:CHS VIRGINIA MEDICAL, PC
Entity Type:Organization
Organization Name:CHS VIRGINIA MEDICAL, PC
Other - Org Name:GOODLIFE HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VP
Authorized Official - Prefix:
Authorized Official - First Name:STUART
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-760-0700
Mailing Address - Street 1:5500 MARYLAND WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4973
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1901 GOODYEAR BLVD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-6607
Practice Address - Country:US
Practice Address - Phone:434-791-9262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHS HEALTH SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-09
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty