1578979886 NPI number — KENT VILLAGE MEDICAL CENTER, LLC

Table of Contents

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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