Provider Demographics
NPI:1790204196
Name:VIRGINIA LICE REMOVAL, LLC
Entity Type:Organization
Organization Name:VIRGINIA LICE REMOVAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:WOLBURG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-387-6509
Mailing Address - Street 1:12605 SOUTHWICK TER
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-2848
Mailing Address - Country:US
Mailing Address - Phone:804-387-6509
Mailing Address - Fax:
Practice Address - Street 1:1901 HUGUENOT RD STE 101
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-4311
Practice Address - Country:US
Practice Address - Phone:804-337-3124
Practice Address - Fax:804-337-3124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-17
Last Update Date:2017-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Single Specialty