Provider Demographics
NPI:1245598085
Name:MEDICAL MANAGEMENT OF VIRGINIA, LLC
Entity Type:Organization
Organization Name:MEDICAL MANAGEMENT OF VIRGINIA, LLC
Other - Org Name:NATURAL HORIZONS WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCKNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-246-9355
Mailing Address - Street 1:11230 WAPLES MILL RD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6087
Mailing Address - Country:US
Mailing Address - Phone:703-246-9355
Mailing Address - Fax:703-267-6977
Practice Address - Street 1:11230 WAPLES MILL RD
Practice Address - Street 2:SUITE 125
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6087
Practice Address - Country:US
Practice Address - Phone:703-246-9355
Practice Address - Fax:703-267-6977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service