Provider Demographics
NPI:1124373808
Name:IPS OF WINCHESTER LLC/AFP LOCATION
Entity Type:Organization
Organization Name:IPS OF WINCHESTER LLC/AFP LOCATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:NELSON
Authorized Official - Last Name:GUSTIN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:540-667-8724
Mailing Address - Street 1:148 LINDEN DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-6902
Mailing Address - Country:US
Mailing Address - Phone:540-504-0075
Mailing Address - Fax:540-678-9025
Practice Address - Street 1:1867 AMHERST ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2801
Practice Address - Country:US
Practice Address - Phone:540-667-8724
Practice Address - Fax:540-723-0741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-18
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty