Healthcare Provider Details

I. General information

NPI: 1306106182
Provider Name (Legal Business Name): CHANTILLY FAMILY MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2012
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14113 ROBERT PARIS CT
CHANTILLY VA
20151-4200
US

IV. Provider business mailing address

14113 ROBERT PARIS CT
CHANTILLY VA
20151-4200
US

V. Phone/Fax

Practice location:
  • Phone: 703-956-6757
  • Fax: 855-359-2261
Mailing address:
  • Phone: 39-566-7577
  • Fax: 855-359-2261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101242454
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KANIKA GOVIL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 703-599-8463