1710069950 NPI number — NORTHERN VIRGINIA VISION CENTER, INC.

Table of content: (NPI 1710069950)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710069950 NPI number — NORTHERN VIRGINIA VISION CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN VIRGINIA VISION CENTER, INC.
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:
1710069950
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21475 RIDGETOP CIR
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
STERLING
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20166-6580
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-430-4400
Provider Business Mailing Address Fax Number:
703-430-4130

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21475 RIDGETOP CIRCLE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
STERLING
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20166-6580
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-430-4400
Provider Business Practice Location Address Fax Number:
703-430-4130
Provider Enumeration Date:
10/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOUTROS
Authorized Official First Name:
AYMAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
703-430-4400

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  0618-000230 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207W00000X , with the licence number: 0101-043806 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0858550001 . This is a "DEMERC STERLING OFFICE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 4147 . This is a "BCBS NCA/CAPITAL CARE" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 0858550003 . This is a "DEMERC FAIRFAX OFFICE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 0858550002 . This is a "DEMERC ALEXANDRIA OFFICE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 0858550004 . This is a "DEMERC LEESBURG OFFICE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 8956502 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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