MEDICARE: GREATER PRINCE WILLIAM AREA COMMUNITY HEATLH CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1942527874
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREATER PRINCE WILLIAM AREA COMMUNITY HEATLH CENTER

Provider Business Mailing Address
First Line	:	PO BOX 6966
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23230-0966
Country	:	US
Telephone Number	:	804-237-7690
Fax Number	:	804-237-7697

Provider Business Practice Location Address
First Line	:	4379 RIDGEWOOD CENTER DR
Second Line	:	SUITE 102
City	:	WOODBRIDGE
State	:	VA
Zip	:	22192-8322
Country	:	US
Telephone Number	:	703-680-7950
Fax Number	:	703-680-7953

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	FRANK PRINCIPI
Credential	:
Telephone Number	:	703-680-7950

Provider Enumeration Date	:	05/03/2010
Last Update Date	:	07/22/2010

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