=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427534072
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEGACY DIALYSIS OF FAIRFAX LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2018
-----------------------------------------------------
Last Update Date | 02/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10565 FAIRFAX BLVD STE 205
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22030-3104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-340-3221
-----------------------------------------------------
Fax | 571-340-3404
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 E SAMPLE RD STE 301
-----------------------------------------------------
City | POMPANO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33064-3552
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-781-7741
-----------------------------------------------------
Fax | 888-349-8679
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MS. MYRLENE BARRERA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-778-8277
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0700X
-----------------------------------------------------
Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------