Provider Demographics
NPI:1548819014
Name:GREENBRIER HEALTH AND WELLNESS CENTER LLC
Entity type:Organization
Organization Name:GREENBRIER HEALTH AND WELLNESS CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIBELLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BLACKMON
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:757-609-3301
Mailing Address - Street 1:1226 PROGRESSIVE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-2847
Mailing Address - Country:US
Mailing Address - Phone:757-609-3301
Mailing Address - Fax:
Practice Address - Street 1:1226 PROGRESSIVE DR STE 101
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-2847
Practice Address - Country:US
Practice Address - Phone:757-609-3301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-08
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty