Provider Demographics
NPI:1265044614
Name:DACOSTA, JUAN P
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:P
Last Name:DACOSTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13800 COPPERMINE RD
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-6163
Mailing Address - Country:US
Mailing Address - Phone:804-446-0975
Mailing Address - Fax:
Practice Address - Street 1:13800 COPPERMINE RD
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20171-6163
Practice Address - Country:US
Practice Address - Phone:804-446-0975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)