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General NPI Number Information
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NPI Number | 1578979886
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Entity Type | Organization
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Legal Business Name | KENT VILLAGE MEDICAL CENTER, LLC
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Dates
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Enumeration Date | 07/08/2014
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Last Update Date | 07/08/2014
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Provider Practice Location Address
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Address Line | 112 KENT VILLAGE SQ
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City | MANASSAS PARK
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State | VA
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Zip | 20111-4155
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Country | US
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Telephone | 703-715-9700
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Fax | 703-715-0202
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Provider Business Mailing Address
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Address Line | 3700 JOSEPH SIEWICK DR SUITE 401
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City | FAIRFAX
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State | VA
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Zip | 22033-1744
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Country | US
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Telephone | 703-715-9700
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Fax | 703-715-0202
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Authorized Official
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Title or Position | OWNER
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Name | DR. FEDERICO CARLOS GONZALES
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Credential | M.D.
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Telephone | 703-715-9700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number | 0101028651
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License Number State | VA
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