Healthcare Provider Details

I. General information

NPI: 1497079073
Provider Name (Legal Business Name): CHANTILLY SPECIALISTS, LTD. OF VIRGINIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2010
Last Update Date: 02/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 LAFAYETTE CENTER DR STE R
CHANTILLY VA
20151-1241
US

IV. Provider business mailing address

4200 LAFAYETTE CENTER DR STE R
CHANTILLY VA
20151-1241
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 TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. PAUL BOCCONE
Title or Position: PRESIDENT
Credential: J.D., LL.M.
Phone: 703-378-3854