Basic Information
Provider Information | |||||||||
NPI: | 1629325758 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LOUDOUN COMMUNITY HEALTH CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HEALTHWORKS FOR NORTHERN VIRGINIA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 163 FORT EVANS RD NE | ||||||||
Address2: |   | ||||||||
City: | LEESBURG | ||||||||
State: | VA | ||||||||
PostalCode: | 201764420 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7038404707 | ||||||||
FaxNumber: | 7037714120 | ||||||||
Practice Location | |||||||||
Address1: | 1141 ELDEN STREET | ||||||||
Address2: | THIRD FLOOR | ||||||||
City: | HERNDON | ||||||||
State: | VA | ||||||||
PostalCode: | 201705573 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7034818160 | ||||||||
FaxNumber: | 7034356752 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/08/2012 | ||||||||
LastUpdateDate: | 10/29/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JAMESON | ||||||||
AuthorizedOfficialFirstName: | CAROL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 7038404704 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MSW | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 1629325758 | 05 | VA |   | MEDICAID |