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General NPI Number Information
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NPI Number | 1235475682
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Entity Type | Organization
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Legal Business Name | ETNACARE, LLC
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Dates
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Enumeration Date | 12/12/2012
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Last Update Date | 12/12/2012
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Provider Practice Location Address
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Address Line | 45800 JONA DR
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City | STERLING
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State | VA
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Zip | 20165-5685
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Country | US
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Telephone | 703-430-0681
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2504
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City | RESTON
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State | VA
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Zip | 20195-0504
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | NEVEN A UJEVIC
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Credential |
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Telephone | 703-430-0681
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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 | 0101047083
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License Number State | VA
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