Healthcare Provider Details

I. General information

NPI: 1174860480
Provider Name (Legal Business Name): HEALTHMSO OF VA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2013
Last Update Date: 01/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11335 SUNSET HILLS RD
RESTON VA
20190-5205
US

IV. Provider business mailing address

PO BOX 1071
BOCA RATON FL
33429-1071
US

V. Phone/Fax

Practice location:
  • Phone: 703-348-7857
  • Fax: 703-444-4308
Mailing address:
  • Phone: 703-348-7857
  • Fax: 703-444-4308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PANKAJ MERCHIA
Title or Position: MANAGER
Credential:
Phone: 703-348-7857