Healthcare Provider Details

I. General information

NPI: 1154898997
Provider Name (Legal Business Name): REGIONAL HEALTH PROVIDERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2018
Last Update Date: 10/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3917 OLD LEE HWY STE 11D
FAIRFAX VA
22030-2431
US

IV. Provider business mailing address

3917 OLD LEE HWY STE 11D
FAIRFAX VA
22030-2431
US

V. Phone/Fax

Practice location:
  • Phone: 703-691-4000
  • Fax: 703-691-4010
Mailing address:
  • Phone: 703-691-4000
  • Fax: 703-691-4010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: EVELYN LOCH
Title or Position: CREDENTIALING BILLING MANAGER
Credential:
Phone: 703-249-9079