1578979886 NPI number — KENT VILLAGE MEDICAL CENTER, LLC

Table of content: (NPI 1578979886)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578979886 NPI number — KENT VILLAGE MEDICAL CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENT VILLAGE MEDICAL CENTER, LLC
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:
1578979886
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3700 JOSEPH SIEWICK DR
Provider Second Line Business Mailing Address:
SUITE 401
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22033-1744
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-715-9700
Provider Business Mailing Address Fax Number:
703-715-0202

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 KENT VILLAGE SQ
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANASSAS PARK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20111-4155
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-715-9700
Provider Business Practice Location Address Fax Number:
703-715-0202
Provider Enumeration Date:
07/08/2014

Additional Information

Authorized Official

Authorized Official Last Name:
GONZALES
Authorized Official First Name:
FEDERICO
Authorized Official Middle Name:
CARLOS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
703-715-9700

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X , with the licence number:  0101028651 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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