Healthcare Provider Details

I. General information

NPI: 1275987570
Provider Name (Legal Business Name): TIMOTHY T HUYNH A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2016
Last Update Date: 04/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 PATRIOT CIR
FAIRFAX VA
22030-4468
US

IV. Provider business mailing address

13392 CABALLERO WAY
CLIFTON VA
20124-1004
US

V. Phone/Fax

Practice location:
  • Phone: 703-993-3279
  • Fax:
Mailing address:
  • Phone: 703-994-9197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126002382
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: