1154428605 NPI number — COMMONWEALTH OF VIRGINIA STATE BOARD OF HEALTH

Table of content: (NPI 1154428605)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154428605 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:
1154428605
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 HARRISON ST SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEESBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20175
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-771-5829
Provider Business Mailing Address Fax Number:
703-771-5023

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 HERITAGE WAY NE
Provider Second Line Business Practice Location Address:
1ST FLOOR SUITE #100
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20176
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-777-0236
Provider Business Practice Location Address Fax Number:
703-771-5393
Provider Enumeration Date:
09/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GOODFRIEND
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
P
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
703-771-5829

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: 004975677 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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