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General NPI Number Information
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NPI Number | 1689629255
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL HEALTHCARE GROUP
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Dates
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Enumeration Date | 05/23/2006
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Last Update Date | 10/03/2008
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Provider Practice Location Address
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Address Line | 5504 STAPLES MILL PLZ
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City | WOODBRIDGE
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State | VA
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Zip | 22193-3247
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Country | US
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Telephone | 703-580-7192
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Fax | 703-580-7183
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Provider Business Mailing Address
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Address Line | PO BOX 6400
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City | WOODBRIDGE
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State | VA
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Zip | 22195-6400
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Country | US
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Telephone | 703-490-8106
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Fax | 703-580-7183
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. ANNETTE FLEMING MCCLATCHEY
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Credential |
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Telephone | 703-580-7192
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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 | 49D1010340
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 0206009192
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License Number State | VA
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