Provider Demographics
NPI:1184027161
Name:OLD TOWN MANASSAS MEDICAL CENTER
Entity Type:Organization
Organization Name:OLD TOWN MANASSAS MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FLAVIANO
Authorized Official - Middle Name:
Authorized Official - Last Name:DAZO
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-BC
Authorized Official - Phone:703-365-0397
Mailing Address - Street 1:9003 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-5410
Mailing Address - Country:US
Mailing Address - Phone:703-365-0397
Mailing Address - Fax:703-365-0399
Practice Address - Street 1:9003 CHURCH ST
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-5410
Practice Address - Country:US
Practice Address - Phone:703-365-0397
Practice Address - Fax:703-365-0399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0663198-0261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center