1013335371 NPI number — BRADLEE FAMILY HEALTH CENTER

Table of content: (NPI 1013335371)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013335371 NPI number — BRADLEE FAMILY HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRADLEE FAMILY HEALTH CENTER
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:
1013335371
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3541 W BRADDOCK RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22302-1915
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-379-6020
Provider Business Mailing Address Fax Number:
703-820-8799

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3541 W BRADDOCK RD
Provider Second Line Business Practice Location Address:
101
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22302-1915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-379-6020
Provider Business Practice Location Address Fax Number:
703-820-8799
Provider Enumeration Date:
04/03/2014

Additional Information

Authorized Official

Authorized Official Last Name:
GONDOR
Authorized Official First Name:
LESLIE
Authorized Official Middle Name:
GEORGE
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
703-379-6020

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  101223709 , 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)

  • Identifier: 2466957 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4718781 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3681092 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7782527 . This is a "AETNA PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 283569 . This is a "INTOTAL" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 172715 . This is a "ANTHEM HEALTHKEEPERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5613060 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: K2040001 . This is a "BCBS" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".




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