Provider Demographics
NPI:1043713399
Name:HARGROVE, DWAYNE
Entity type:Individual
Prefix:
First Name:DWAYNE
Middle Name:
Last Name:HARGROVE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 CHERRY HILL DR
Mailing Address - Street 2:
Mailing Address - City:RUSTBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24588-4244
Mailing Address - Country:US
Mailing Address - Phone:434-509-9100
Mailing Address - Fax:
Practice Address - Street 1:339 CHERRY HILL DR
Practice Address - Street 2:
Practice Address - City:RUSTBURG
Practice Address - State:VA
Practice Address - Zip Code:24588-4244
Practice Address - Country:US
Practice Address - Phone:434-509-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT60723797172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver