Healthcare Provider Details

I. General information

NPI: 1194423020
Provider Name (Legal Business Name): HECTOR R DURAND CONCHA RDMS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12480 SKIPPER CIR
WOODBRIDGE VA
22192-2350
US

IV. Provider business mailing address

12480 SKIPPER CIR
WOODBRIDGE VA
22192-2350
US

V. Phone/Fax

Practice location:
  • Phone: 571-477-9504
  • Fax:
Mailing address:
  • Phone: 571-477-9504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number198384
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: