Healthcare Provider Details

I. General information

NPI: 1033268347
Provider Name (Legal Business Name): NIYADELL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 02/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 KENMORE AVE SUITE 101
ALEXANDRIA VA
22304-1306
US

IV. Provider business mailing address

4660 KENMORE AVE SUITE 101
ALEXANDRIA VA
22304-1306
US

V. Phone/Fax

Practice location:
  • Phone: 703-751-2800
  • Fax: 703-751-3771
Mailing address:
  • Phone: 703-751-2800
  • Fax: 703-751-3771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number1101001255
License Number StateVA

VIII. Authorized Official

Name: MS. NANCY LYNN BENJAMIN
Title or Position: PRESIDENT
Credential: LDO
Phone: 703-751-2800