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General NPI Number Information
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NPI Number | 1174841324
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Entity Type | Organization
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Legal Business Name | CLINICA OF VIRGINIA LLC
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Dates
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Enumeration Date | 05/12/2010
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Last Update Date | 05/12/2010
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Provider Practice Location Address
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Address Line | 10560 MAIN ST #215
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City | FAIRFAX
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State | VA
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Zip | 22030-7182
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Country | US
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Telephone | 571-432-0700
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Fax |
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Provider Business Mailing Address
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Address Line | 1600 TYSONS BLVD 8TH FLOOR
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City | MC LEAN
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State | VA
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Zip | 22102-4865
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Country | US
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Telephone | 703-245-8513
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Fax | 703-245-3001
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Authorized Official
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Title or Position | EXECUTIVE GENERAL MANAGER
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Name | MR. WOODROW ALLEN BOYER
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Credential | EGM
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Telephone | 863-614-0371
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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