Provider Demographics
NPI:1073279378
Name:MOA MID-ATLANTIC LLC
Entity Type:Organization
Organization Name:MOA MID-ATLANTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO / DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:703-719-8811
Mailing Address - Street 1:3910 CENTREVILLE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-3280
Mailing Address - Country:US
Mailing Address - Phone:703-719-8811
Mailing Address - Fax:703-263-2441
Practice Address - Street 1:3910 CENTREVILLE RD STE 102
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-3280
Practice Address - Country:US
Practice Address - Phone:703-719-8811
Practice Address - Fax:703-263-2441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-10
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty