1275669277 NPI number — COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH

Table of content: DR. LAUREN RAYBOULD KELLY UGARTE MD (NPI 1821280645)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275669277 NPI number — COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275669277
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4480 KING ST
Provider Second Line Business Mailing Address:
SUITE 413
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22302-1300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-746-4967
Provider Business Mailing Address Fax Number:
703-746-4930

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4480 KING ST
Provider Second Line Business Practice Location Address:
SUITE 413
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22302-1300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-746-4967
Provider Business Practice Location Address Fax Number:
703-746-4930
Provider Enumeration Date:
02/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LEVINE
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
R
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
703-746-4967

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4976053 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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