Healthcare Provider Details

I. General information

NPI: 1649215955
Provider Name (Legal Business Name): ALEXANDRIA LAKE RIDGE PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N BEAUREGARD ST STE 200
ALEXANDRIA VA
22311-1700
US

IV. Provider business mailing address

1500 N BEAUREGARD ST STE 200
ALEXANDRIA VA
22311-1700
US

V. Phone/Fax

Practice location:
  • Phone: 703-436-1200
  • Fax: 703-499-9670
Mailing address:
  • Phone: 703-436-1200
  • Fax: 703-499-9670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number101038289
License Number StateVA

VIII. Authorized Official

Name: KAREN HOFFER
Title or Position: CLINICAL ADMINISTRTOR
Credential:
Phone: 703-436-1200