Provider Demographics
NPI:1811221229
Name:CHILDREN'S MEDICAL CENTER, LTD.
Entity Type:Organization
Organization Name:CHILDREN'S MEDICAL CENTER, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:LAFAVE
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:276-632-9714
Mailing Address - Street 1:15 CLEVELAND AVENUE,
Mailing Address - Street 2:SUITE 14
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112
Mailing Address - Country:US
Mailing Address - Phone:276-632-9714
Mailing Address - Fax:276-632-0620
Practice Address - Street 1:15 CLEVELAND AVE
Practice Address - Street 2:SUITE 14
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-2937
Practice Address - Country:US
Practice Address - Phone:276-632-9714
Practice Address - Fax:276-632-0620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101246331174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty