| County Med, Llc | |
|
103 E Broad St Blackstone VA 23824-1815 | |
| (434) 264-3221 | |
| Not Available |
| Full Name | County Med, Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 103 E Broad St, Blackstone, Virginia |
| Authorized Official Name and Position | Shantel Latta (OWNER) |
| Authorized Official Contact | 4342943825 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| County Med, Llc Po Box 635 Blackstone VA 23824-0635 Ph: () - | County Med, Llc 103 E Broad St Blackstone VA 23824-1815 Ph: (434) 264-3221 |
| NPI Number | 1407580483 |
|---|---|
| Provider Enumeration Date | 07/14/2022 |
| Last Update Date | 08/01/2023 |
| Medicare PECOS PAC ID | 4082083928 |
|---|---|
| Medicare Enrollment ID | O20221215000538 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1407580483 | NPI | - | NPPES |
| 30017485050002 | Medicaid | VA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QP2300X | Clinic/center - Primary Care | (* (Not Available)) | Primary |
| Provider Name | Shantel Latta |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1962092932 PECOS PAC ID: 1254727290 Enrollment ID: I20220331000916 |
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Blackstone Family Practice Center Primary Care Clinic Medicare: Not Enrolled in Medicare Practice Location: 213 N Main St, Blackstone, VA 23824 Phone: 434-292-7261 Fax: 434-292-7965 | |
Blackstone Family Practice Center Primary Care Clinic Medicare: Not Enrolled in Medicare Practice Location: 213 N Main St, Blackstone, VA 23824 Phone: 434-292-7261 Fax: 434-298-0908 | |
Blackstone Family Practice Center Primary Care Clinic Medicare: Not Enrolled in Medicare Practice Location: 213 N Main St, Blackstone, VA 23824 Phone: 434-292-7261 Fax: 434-298-0908 |