Provider Demographics
NPI:1730304742
Name:WELLSPRING FAMILY MEDICAL CENTER
Entity Type:Organization
Organization Name:WELLSPRING FAMILY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:RILES
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:757-312-0166
Mailing Address - Street 1:648 INDEPENDENCE PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-5206
Mailing Address - Country:US
Mailing Address - Phone:757-312-0166
Mailing Address - Fax:757-312-8116
Practice Address - Street 1:648 INDEPENDENCE PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-5206
Practice Address - Country:US
Practice Address - Phone:757-312-0166
Practice Address - Fax:757-312-8116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101044787208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101044787OtherSTATE LICENSE
VAE60365Medicare UPIN