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General NPI Number Information
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NPI Number | 1669804159
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Entity Type | Organization
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Legal Business Name | VIP IMED CENTER
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Dates
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Enumeration Date | 08/06/2013
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Last Update Date | 02/07/2014
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Provider Practice Location Address
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Address Line | 8303 ARLINGTON BLVD SUITE 110
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City | FAIRFAX
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State | VA
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Zip | 22031-4645
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Country | US
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Telephone | 703-207-4646
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Fax | 703-563-7467
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Provider Business Mailing Address
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Address Line | 8303 ARLINGTON BLVD SUITE 110
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City | FAIRFAX
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State | VA
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Zip | 22031-2903
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Country | US
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Telephone | 703-207-4646
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Fax | 703-563-7467
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | VICTORIA BORISOVNA
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Credential |
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Telephone | 703-207-4646
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 101055521
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 0101255440
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License Number State | VA
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