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General NPI Number Information
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NPI Number | 1053592337
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Entity Type | Organization
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Legal Business Name | CHANTILLY FAMILY PRACTICE
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Dates
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Enumeration Date | 11/15/2007
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Last Update Date | 11/15/2007
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Provider Practice Location Address
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Address Line | 4437 BROOKFIELD CORPORATE DR
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City | CHANTILLY
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State | VA
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Zip | 20151-2122
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Country | US
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Telephone | 703-968-7277
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Fax | 703-968-5644
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Provider Business Mailing Address
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Address Line | 4437 BROOKFIELD CORPORATE DR
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City | CHANTILLY
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State | VA
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Zip | 20151-2122
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Country | US
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Telephone | 703-968-7277
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Fax | 703-968-5644
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. RAJESH N MEHRA
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Credential | D.O
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Telephone | 703-968-7277
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 0102033582
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License Number State | VA
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