Healthcare Provider Details

I. General information

NPI: 1477934727
Provider Name (Legal Business Name): POTOMAC HEALTHCARE SOLUTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2015
Last Update Date: 06/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1549 OLD BRIDGE RD STE 201
WOODBRIDGE VA
22192-2737
US

IV. Provider business mailing address

1549 OLD BRIDGE RD STE 201
WOODBRIDGE VA
22192-2737
US

V. Phone/Fax

Practice location:
  • Phone: 703-498-2773
  • Fax: 703-542-1772
Mailing address:
  • Phone: 703-498-2773
  • Fax: 703-542-1772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberS4081867
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberS4081867
License Number StateVA

VIII. Authorized Official

Name: DAPHNEY JACKSON
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 703-498-2773