Provider Demographics
NPI:1891922928
Name:PRIS,PLC
Entity Type:Organization
Organization Name:PRIS,PLC
Other - Org Name:BRENDA WALLER , MD
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-528-0896
Mailing Address - Street 1:2600 MEMORIAL AVE
Mailing Address - Street 2:SUITE 201B
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-2662
Mailing Address - Country:US
Mailing Address - Phone:434-528-0896
Mailing Address - Fax:434-528-0898
Practice Address - Street 1:2600 MEMORIAL AVE
Practice Address - Street 2:SUITE 201B
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2662
Practice Address - Country:US
Practice Address - Phone:434-528-0896
Practice Address - Fax:434-528-0898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-16
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101055485208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010045100Medicaid
VAE33409Medicare UPIN
VA010045100Medicaid