Healthcare Provider Details

I. General information

NPI: 1356710594
Provider Name (Legal Business Name): DEPARTMENT OF VETERANS AFFAIRS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2015
Last Update Date: 09/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 VERMONT AVE NW
WASHINGTON DC
20420-0001
US

IV. Provider business mailing address

11509 HAVENNER RD
FAIRFAX STATION VA
22039-1220
US

V. Phone/Fax

Practice location:
  • Phone: 202-461-7351
  • Fax:
Mailing address:
  • Phone: 202-461-7351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number5302030607
License Number StateMI

VIII. Authorized Official

Name: DR. THOMAS RYAN EMMENDORFER
Title or Position: DEPUTY CHIEF CONSULTANT
Credential: PHARMD
Phone: 202-461-7351