Provider Demographics
NPI:1982930673
Name:PRIS, PLC
Entity Type:Organization
Organization Name:PRIS, PLC
Other - Org Name:BRENDA WALLER SOLE MEMBER
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 1:1935 THOMSON DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1008
Mailing Address - Country:US
Mailing Address - Phone:434-528-0896
Mailing Address - Fax:434-528-0898
Practice Address - Street 1:1935 THOMSON DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1008
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:2009-10-30
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101055485208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010045100Medicaid
VA010045100Medicaid
VA190001017Medicare PIN