Provider Demographics
NPI:1164874426
Name:PRIVIA CARE CENTER LLC
Entity Type:Organization
Organization Name:PRIVIA CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING & ENROLLMENT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:IVESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-366-8831
Mailing Address - Street 1:950 N GLEBE RD
Mailing Address - Street 2:SUITE 4000
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22203-1824
Mailing Address - Country:US
Mailing Address - Phone:571-366-8850
Mailing Address - Fax:
Practice Address - Street 1:950 N GLEBE RD
Practice Address - Street 2:SUITE 4000
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22203-1824
Practice Address - Country:US
Practice Address - Phone:571-366-8850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-11
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty