Healthcare Provider Details

I. General information

NPI: 1659812832
Provider Name (Legal Business Name): NORTHERN VIRGINIA LABORATORY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 03/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 KENMORE AVE
ALEXANDRIA VA
22304-1313
US

IV. Provider business mailing address

8422 GIRVAN CT
MANASSAS VA
20109
US

V. Phone/Fax

Practice location:
  • Phone: 703-207-7072
  • Fax: 703-207-7074
Mailing address:
  • Phone: 703-207-7072
  • Fax: 703-207-7074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MRS. SANDRA B MADDUX
Title or Position: OWNER/MANAGER
Credential:
Phone: 703-207-7072