Healthcare Provider Details

I. General information

NPI: 1396327052
Provider Name (Legal Business Name): VIV FAIRFAX, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2021
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13135 LEE JACKSON MEMORIAL HWY STE 145
FAIRFAX VA
22033-1907
US

IV. Provider business mailing address

14085 CROWN CT
WOODBRIDGE VA
22193-1458
US

V. Phone/Fax

Practice location:
  • Phone: 215-828-2387
  • Fax:
Mailing address:
  • Phone: 703-763-5224
  • Fax: 703-763-5374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. ANISH P SHAH
Title or Position: CEO
Credential: MD
Phone: 215-828-2387