1316182116 NPI number — ALEXANDRIA LAKE RIDGE PEDIATRICS

Table of content: (NPI 1316182116)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316182116 NPI number — ALEXANDRIA LAKE RIDGE PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALEXANDRIA LAKE RIDGE PEDIATRICS
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:
1316182116
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1707 OSAGE ST
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22302-2607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-212-6600
Provider Business Mailing Address Fax Number:
703-931-0961

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9010 LORTON STATION BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
LORTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22079
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-212-6600
Provider Business Practice Location Address Fax Number:
703-931-0961
Provider Enumeration Date:
12/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FARBER
Authorized Official First Name:
JON
Authorized Official Middle Name:
M
Authorized Official Title or Position:
TREASURER
Authorized Official Telephone Number:
703-212-6600

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  0101038289 , 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)





Copyright © 2007-2025 www.npivalidator.com