=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225337504
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACE MEDICAL CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2011
-----------------------------------------------------
Last Update Date | 01/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9845 GEORGETOWN PIKE
-----------------------------------------------------
City | GREAT FALLS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22066-2617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-757-0311
-----------------------------------------------------
Fax | 703-757-0911
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9845 GEORGETOWN PIKE
-----------------------------------------------------
City | GREAT FALLS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22066-2617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-757-0311
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ALI MIREBRAHIMI-TAFRESHI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 443-739-2315
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 0101247765
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------