Healthcare Provider Details

I. General information

NPI: 1669496790
Provider Name (Legal Business Name): DIAGENETICS OF FREDERICKSBURG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32315 CONSTITUTION HWY
LOCUST GROVE VA
22508-2707
US

IV. Provider business mailing address

PO BOX 2510
LOCUST GROVE VA
22508-8510
US

V. Phone/Fax

Practice location:
  • Phone: 540-854-0120
  • Fax: 540-854-0126
Mailing address:
  • Phone: 540-854-0120
  • Fax: 540-854-0126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateVA

VIII. Authorized Official

Name: DR. DANIEL G STETKA
Title or Position: PRESIDENT/DIRECTOR
Credential: PHD
Phone: 540-854-0125