Details as stated in the register
- DPOR board / occupation / certificate number
- 2705077341
- Source license rank
- C
- Source specialty codes
- HIC
- Source certification date
- 07/15/2004
- Source expiration date
- 07/31/2028
- Address city as filed
- BERRYVILLE
- Address state as filed
- VA
- Address ZIP as filed
- 22611
Register status and classifications are reproduced from the source. No independently verified business activity, customer premises, contact details, insurance or trade license is implied.