Provider Demographics
NPI:1093869976
Name:VIRGINIA RETINA CENTER LLC
Entity Type:Organization
Organization Name:VIRGINIA RETINA CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-443-0015
Mailing Address - Street 1:45 N HILL DR STE 202
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20186-2677
Mailing Address - Country:US
Mailing Address - Phone:540-349-1882
Mailing Address - Fax:703-738-7157
Practice Address - Street 1:45 N HILL DR STE 202
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-2677
Practice Address - Country:US
Practice Address - Phone:540-349-1882
Practice Address - Fax:703-738-7157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01011233782207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010107067Medicaid
VA010107024Medicaid
VA010107024Medicaid
VA010107067Medicaid
DC037331500Medicaid