Healthcare Provider Details

I. General information

NPI: 1427702893
Provider Name (Legal Business Name): LAZARUS PSYCHIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2022
Last Update Date: 06/01/2024
Certification Date: 06/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7535 LITTLE RIVER TPKE STE 200A
ANNANDALE VA
22003-2988
US

IV. Provider business mailing address

7535 LITTLE RIVER TPKE STE 200A
ANNANDALE VA
22003-2988
US

V. Phone/Fax

Practice location:
  • Phone: 202-236-4669
  • Fax: 708-879-8208
Mailing address:
  • Phone: 202-236-4669
  • Fax: 708-879-8208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JAE HOON KIM
Title or Position: OWNER
Credential:
Phone: 202-236-4669