Healthcare Provider Details

I. General information

NPI: 1083797666
Provider Name (Legal Business Name): JEANNETTE LUCILLE LIU O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 LOISDALE RD SUITE S
SPRINGFIELD VA
22150-1902
US

IV. Provider business mailing address

9617 SLOWAY COAST DR
LORTON VA
22079-2789
US

V. Phone/Fax

Practice location:
  • Phone: 703-719-5455
  • Fax:
Mailing address:
  • Phone: 703-495-8226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618001093
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: