Organization
MOUNTAIN REGION FAMILY MEDICINE PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
WANDA Y TRENT (CORPORATE SECRETARY)
(423) 224-3400
Entity
Organization
Contact information
Practice address
142 MEADE AVENUE, NICKELSVILLE, VA 24271
(276) 479-2201
(276) 479-3314
Mailing address
142 MEADE AVENUE, NICKELSVILLE, VA 24271
(276) 479-2201
(276) 479-3314
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0040096
BLUE CROSS BLUE SHIELD
TN
01
—
037069
BLUE CROSS BLUE SHIELD
VA
01
—
265967710
TRICARE/CHAMPUS
—
05
—
4175553
—
TN
05
—
5609933
—
VA
Enumeration date
08/17/2006
Last updated
12/14/2017
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