Healthcare Provider Details

I. General information

NPI: 1508245069
Provider Name (Legal Business Name): POTOMAC HEALTH & WELLNESS (PHW), INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2015
Last Update Date: 01/16/2025
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8321 OLD COURTHOUSE RD STE 202
VIENNA VA
22182-3817
US

IV. Provider business mailing address

PO BOX 5776
ARLINGTON VA
22205-0776
US

V. Phone/Fax

Practice location:
  • Phone: 703-740-4577
  • Fax: 703-448-1257
Mailing address:
  • Phone: 703-740-4577
  • Fax: 703-448-1257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. AMJAD MALIK
Title or Position: VP
Credential:
Phone: 703-740-4577