Healthcare Provider Details

I. General information

NPI: 1790620722
Provider Name (Legal Business Name): IWC SERVICES VIRGINIA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 VILLAGE CIR
BRISTOL VA
24201-8302
US

IV. Provider business mailing address

492C CEDAR LN STE 514
TEANECK NJ
07666-1713
US

V. Phone/Fax

Practice location:
  • Phone: 732-451-4318
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DIANE LUSAS
Title or Position: OWNER
Credential: MD
Phone: 732-451-4318