Provider Demographics
NPI:1033399688
Name:TACKLE MANAGEMENT CORPORATION
Entity Type:Organization
Organization Name:TACKLE MANAGEMENT CORPORATION
Other - Org Name:BULL RUN FOOT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:COATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-368-1800
Mailing Address - Street 1:8637 MATHIS AVE
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-5270
Mailing Address - Country:US
Mailing Address - Phone:703-335-6890
Mailing Address - Fax:
Practice Address - Street 1:8637 MATHIS AVE
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-5270
Practice Address - Country:US
Practice Address - Phone:703-335-6890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA296209OtherANTHEM