Provider Demographics
NPI:1811582448
Name:ELJV LLC
Entity Type:Organization
Organization Name:ELJV LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RUTH ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-938-3654
Mailing Address - Street 1:1729 WILDWOOD DR STE 103A
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-3176
Mailing Address - Country:US
Mailing Address - Phone:757-938-3654
Mailing Address - Fax:757-938-3658
Practice Address - Street 1:1729 WILDWOOD DR STE 103A
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3176
Practice Address - Country:US
Practice Address - Phone:757-938-3654
Practice Address - Fax:757-938-3658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty