Provider Demographics
NPI:1083866867
Name:PROLIFIC VENTURES LLC
Entity Type:Organization
Organization Name:PROLIFIC VENTURES LLC
Other - Org Name:GOOD HEALTH MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THI
Authorized Official - Middle Name:D
Authorized Official - Last Name:HOANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-362-7574
Mailing Address - Street 1:P.O. BOX 5055
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22044-9055
Mailing Address - Country:US
Mailing Address - Phone:888-936-0808
Mailing Address - Fax:877-337-3766
Practice Address - Street 1:6426 CROSSROADS DR
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22044
Practice Address - Country:US
Practice Address - Phone:888-936-0808
Practice Address - Fax:877-337-3766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-13
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4210174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
185262Medicare UPIN