1316161151 NPI number — FAIRFAX MEDICAL CENTER OPTICIAN INC.

Table of content: (NPI 1316161151)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316161151 NPI number — FAIRFAX MEDICAL CENTER OPTICIAN INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRFAX MEDICAL CENTER OPTICIAN INC.
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:
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:
1316161151
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10721 MAIN ST
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22030-6959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-273-4237
Provider Business Mailing Address Fax Number:
703-273-1207

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10721 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
FAIRFAX
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22030-6959
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-273-4237
Provider Business Practice Location Address Fax Number:
703-273-1207
Provider Enumeration Date:
04/12/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FERRARO
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
703-978-5170

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X , with the licence number:  103372 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 332H00000X , with the licence number: 103372 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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