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General NPI Number Information
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NPI Number | 1376853341
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Entity Type | Organization
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Legal Business Name | CHANTILLY SPECIALISTS, LTD. OF VIRGINIA
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Dates
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Enumeration Date | 10/08/2010
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Last Update Date | 10/08/2010
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Provider Practice Location Address
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Address Line | 14121 PARKE LONG CT SUITE 112
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City | CHANTILLY
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State | VA
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Zip | 20151-1647
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Country | US
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Telephone | 571-251-5471
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Fax | 703-378-4909
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Provider Business Mailing Address
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Address Line | 14121 PARKE LONG CT SUITE 112
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City | CHANTILLY
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State | VA
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Zip | 20151-1647
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Country | US
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Telephone | 571-251-5471
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Fax | 703-378-4909
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. PAUL P BOCCONE
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Credential | J.D., LL.M.
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Telephone | 571-251-5471
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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 | 49D2006729
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License Number State | VA
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