Individual
OMAR EDMOND
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
118 FAYETTE ST, SUFFOLK, VA 23434-5458
(757) 477-4847
Mailing address
118 FAYETTE ST, SUFFOLK, VA 23434-5458
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
A69694616
VA
Other
Enumeration date
06/28/2017
Last updated
06/28/2017
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