Healthcare Provider Details

I. General information

NPI: 1922024041
Provider Name (Legal Business Name): PET OF RESTON, LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 04/21/2023
Certification Date: 04/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 TOWN CENTER DRIVE SUITE 105
RESTON VA
20190-3237
US

IV. Provider business mailing address

P.O. BOX 207421
DALLAS TX
75320-7421
US

V. Phone/Fax

Practice location:
  • Phone: 571-601-2901
  • Fax: 571-577-4142
Mailing address:
  • Phone: 703-726-1201
  • Fax: 703-726-1053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY ATKIN
Title or Position: CEO
Credential: MBA, MIS, CPHIMS
Phone: 703-726-1201