Healthcare Provider Details

I. General information

NPI: 1952878365
Provider Name (Legal Business Name): JUSTIN FELIX IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4747 W BRADDOCK RD APT 3
ALEXANDRIA VA
22311-4722
US

IV. Provider business mailing address

4747 W BRADDOCK RD APT 3
ALEXANDRIA VA
22311-4722
US

V. Phone/Fax

Practice location:
  • Phone: 302-222-3634
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: