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General NPI Number Information
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NPI Number | 1730532359
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Entity Type | Organization
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Legal Business Name | VITA FAMILY MEDICINE AND MEDSPA LLC
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Dates
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Enumeration Date | 07/19/2016
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Last Update Date | 10/13/2016
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Provider Practice Location Address
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Address Line | 540 FORT EVANS RD SUITE 204
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City | LEESBURG
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State | VA
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Zip | 20176-3379
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Country | US
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Telephone | 703-737-3500
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Fax | 703-737-3550
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Provider Business Mailing Address
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Address Line | 540 FORT EVANS RD SUITE 204
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City | LEESBURG
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State | VA
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Zip | 20176-3379
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Country | US
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Telephone | 703-737-3500
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Fax | 703-737-3550
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Authorized Official
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Title or Position | OWNER/DOCTOR
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Name | DR. JENNIFER BOUDREAU
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Credential | M.D
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Telephone | 717-805-8264
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 0101258315
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State | VA
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