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General NPI Number Information
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NPI Number | 1467974634
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Entity Type | Organization
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Legal Business Name | FAIR LAKES OPTOMETRY
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Dates
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Enumeration Date | 07/10/2017
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Last Update Date | 07/25/2017
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Provider Practice Location Address
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Address Line | 13047 FAIR LAKES SHOPPING CTR
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City | FAIRFAX
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State | VA
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Zip | 22033-5179
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Country | US
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Telephone | 703-502-3090
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Fax |
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Provider Business Mailing Address
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Address Line | 12587 FAIR LAKES CIR # 502
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City | FAIRFAX
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State | VA
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Zip | 22033-3822
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Country | US
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Telephone | 703-502-3090
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. ANH NGUYEN
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Credential | OD
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Telephone | 571-435-4558
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 0618002149
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License Number State | VA
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