Provider Demographics
NPI:1255856019
Name:PENDLETOM, CORNELL
Entity type:Individual
Prefix:
First Name:CORNELL
Middle Name:
Last Name:PENDLETOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6455 HICKORY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SPOTSYLVANIA
Mailing Address - State:VA
Mailing Address - Zip Code:22551-2456
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6455 HICKORY RIDGE RD
Practice Address - Street 2:
Practice Address - City:SPOTSYLVANIA
Practice Address - State:VA
Practice Address - Zip Code:22551-2456
Practice Address - Country:US
Practice Address - Phone:540-379-7204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-13
Last Update Date:2017-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT63451175172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver