Provider Demographics
NPI:1831128032
Name:COLONIAL BEACH MEDICAL CENTER
Entity Type:Organization
Organization Name:COLONIAL BEACH MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KELL
Authorized Official - Middle Name:R
Authorized Official - Last Name:HOOVLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-657-9633
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:GARRISONVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22463-0099
Mailing Address - Country:US
Mailing Address - Phone:540-657-9633
Mailing Address - Fax:540-657-5925
Practice Address - Street 1:700 MCKINNEY BLVD
Practice Address - Street 2:STE. 12
Practice Address - City:COLONIAL BEACH
Practice Address - State:VA
Practice Address - Zip Code:22443-1925
Practice Address - Country:US
Practice Address - Phone:804-224-6322
Practice Address - Fax:804-224-2512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09297Medicare ID - Type UnspecifiedMEDICARE FACILITY NUMBER