Basic Information
| Provider Information | |||||||||
| NPI: | 1750612495 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL MANAGEMENT OF VA LLC | ||||||||
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| OtherOrganizationName: | HORIZONS OF HOPE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11230 WAPLES MILL RD | ||||||||
| Address2: | SUITE 125 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220306087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545877771 | ||||||||
| FaxNumber: | 9542085770 | ||||||||
| Practice Location | |||||||||
| Address1: | 10640 MAIN ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220303821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545877771 | ||||||||
| FaxNumber: | 9542085770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2010 | ||||||||
| LastUpdateDate: | 01/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | EWENS | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9545877771 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BRIDGING THE GAPS | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 42902001 | VA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.