Healthcare Provider Details

I. General information

NPI: 1497808679
Provider Name (Legal Business Name): INOVA KELLAR CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11204 WAPLES MILL RD
FAIRFAX VA
22030-6048
US

IV. Provider business mailing address

PO BOX 1110
FAIRFAX VA
22038-1110
US

V. Phone/Fax

Practice location:
  • Phone: 703-218-8500
  • Fax: 703-359-0463
Mailing address:
  • Phone: 703-218-8500
  • Fax: 703-359-0463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number033
License Number StateVA

VIII. Authorized Official

Name: DR. RICK LEICHTWEIS
Title or Position: SENIOR DIRECTOR
Credential: PH.D
Phone: 703-218-8500