Healthcare Provider Details

I. General information

NPI: 1134049885
Provider Name (Legal Business Name): GIANNI SALVATORE KUBANCIK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7960 DONEGAN DR STE 200
MANASSAS VA
20109-8236
US

IV. Provider business mailing address

13160 BOURNE PL
BRISTOW VA
20136-1029
US

V. Phone/Fax

Practice location:
  • Phone: 571-229-3159
  • Fax:
Mailing address:
  • Phone: 571-229-3159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: