Organization
DOC BOX
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JACKSON GREEN (ADMINISTRATOR)
(804) 286-6224
Entity
Organization
Contact information
Practice address
2400 OLD BRICK RD STE 60, GLEN ALLEN, VA 23060-5841
(804) 286-6224
Mailing address
2400 OLD BRICK RD STE 60, GLEN ALLEN, VA 23060-5841
(804) 286-6224
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
—
—
261Q00000X
Clinic/Center
—
—
261QP2300X
Primary Care Clinic/Center
—
—
261QU0200X
Urgent Care Clinic/Center
Primary
—
—
Other
Enumeration date
09/10/2025
Last updated
09/10/2025
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