Provider Demographics
NPI:1770813230
Name:CHIPPENHAM & JOHNSTON WILLIS SPORTS MEDICINE, LLC
Entity type:Organization
Organization Name:CHIPPENHAM & JOHNSTON WILLIS SPORTS MEDICINE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:HUNTER
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DURVIN
Authorized Official - Suffix:
Authorized Official - Credentials:ATC
Authorized Official - Phone:804-560-6511
Mailing Address - Street 1:500 HIOAKS RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4061
Mailing Address - Country:US
Mailing Address - Phone:804-560-6500
Mailing Address - Fax:804-560-6505
Practice Address - Street 1:11621 ROBIOUS RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-2349
Practice Address - Country:US
Practice Address - Phone:804-560-6500
Practice Address - Fax:804-560-6505
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHIPPENHAM & JOHNSTON WILLIS HOSPITALS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-06
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty