Provider Demographics
NPI:1487703211
Name:CREECH, JUSTIN (PBSF)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:CREECH
Suffix:
Gender:M
Credentials:PBSF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4903 MEREDITH WOODS RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-3113
Mailing Address - Country:US
Mailing Address - Phone:804-402-6134
Mailing Address - Fax:
Practice Address - Street 1:4903 MEREDITH WOODS RD
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-3113
Practice Address - Country:US
Practice Address - Phone:804-402-6134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA109174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist