Healthcare Provider Details

I. General information

NPI: 1407079155
Provider Name (Legal Business Name): NORTHERN VIRGINIA EYE SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 10/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 PROSPERITY AVE SUITE 150
FAIRFAX VA
22031-4320
US

IV. Provider business mailing address

2710 PROSPERITY AVE SUITE 150
FAIRFAX VA
22031-4320
US

V. Phone/Fax

Practice location:
  • Phone: 703-289-1290
  • Fax: 703-289-1298
Mailing address:
  • Phone: 703-289-1290
  • Fax: 703-289-1298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberOH712
License Number StateVA

VIII. Authorized Official

Name: DR. WILLIAM RICH III
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 703-534-3900