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General NPI Number Information
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NPI Number | 1104852573
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Entity Type | Organization
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Legal Business Name | FAIRFAX MEDICAL LABORATORIES, INC.
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Dates
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Enumeration Date | 06/25/2006
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Last Update Date | 01/10/2013
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Provider Practice Location Address
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Address Line | 4200 PLEASANT VALLEY RD
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City | CHANTILLY
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State | VA
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Zip | 20151-1211
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Country | US
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Telephone | 703-222-2313
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Fax | 703-263-2582
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Provider Business Mailing Address
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Address Line | 4200 PLEASANT VALLEY RD
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City | CHANTILLY
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State | VA
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Zip | 20151-1211
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Country | US
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Telephone | 703-222-2313
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Fax | 703-263-2582
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | MR. ROBERT FREDERICKS
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Credential |
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Telephone | 703-222-2313
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 49D0221827
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License Number State | VA
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