Healthcare Provider Details

I. General information

NPI: 1598761249
Provider Name (Legal Business Name): PTAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 09/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21475 RIDGETOP CIRCLE SUITE 260
STERLING VA
20166-6580
US

IV. Provider business mailing address

21475 RIDGETOP CIR STE 260
STERLING VA
20166-8580
US

V. Phone/Fax

Practice location:
  • Phone: 703-433-0401
  • Fax: 703-433-0490
Mailing address:
  • Phone: 703-433-0401
  • Fax: 703-433-0490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberB501869
License Number StateVA

VIII. Authorized Official

Name: MR. HUGH FRANCIS BRADIN JR.
Title or Position: CO-OWNER
Credential:
Phone: 703-433-0401