Provider Demographics
NPI:1063844421
Name:SOUTH BAYLO CLINIC
Entity Type:Organization
Organization Name:SOUTH BAYLO CLINIC
Other - Org Name:SOUTH BAYLO UNIVERSITY VA CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:TAE
Authorized Official - Middle Name:O
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-762-6048
Mailing Address - Street 1:7535 LITTLE RIVER TURNPIKE
Mailing Address - Street 2:310E
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003
Mailing Address - Country:US
Mailing Address - Phone:703-642-7527
Mailing Address - Fax:703-642-7528
Practice Address - Street 1:7535 LITTLE RIVER TURNPIKE
Practice Address - Street 2:310E
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003
Practice Address - Country:US
Practice Address - Phone:703-642-7527
Practice Address - Fax:703-642-7528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000694171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty