Healthcare Provider Details

I. General information

NPI: 1265444053
Provider Name (Legal Business Name): CHANTILLY SPECIALISTS, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 05/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14121 PARKE LONG CT SUITE 112
CHANTILLY VA
20151-1647
US

IV. Provider business mailing address

14121 PARKE LONG CT SUITE 112
CHANTILLY VA
20151-1647
US

V. Phone/Fax

Practice location:
  • Phone: 703-378-3854
  • Fax: 703-378-4909
Mailing address:
  • Phone: 703-378-3854
  • Fax: 703-378-4909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: ROBERTA MILLSAP
Title or Position: ADMIN ASSISTANT
Credential:
Phone: 703-378-3854