Healthcare Provider Details

I. General information

NPI: 1245297506
Provider Name (Legal Business Name): ALEXANDRIA GERIATRIC CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 10/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10006 THOMPSON RIDGE CT
GREAT FALLS VA
22066
US

IV. Provider business mailing address

PO BOX 641
GREAT FALLS VA
22066-0641
US

V. Phone/Fax

Practice location:
  • Phone: 703-759-6294
  • Fax: 703-759-2724
Mailing address:
  • Phone: 703-759-2724
  • Fax: 703-759-2724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101033583
License Number StateVA

VIII. Authorized Official

Name: MS. DEBORAH ANN WALCZAK
Title or Position: MEDICAL BILLER
Credential:
Phone: 703-759-2724