Provider Demographics
NPI:1356857098
Name:CAVERY WELLNESS OF FAIRFAX, LLC
Entity Type:Organization
Organization Name:CAVERY WELLNESS OF FAIRFAX, LLC
Other - Org Name:MEDI WEIGHTLOSS OF FAIRFAX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARSHBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:571-408-9139
Mailing Address - Street 1:14610 SULKY RUN CT
Mailing Address - Street 2:
Mailing Address - City:NOKESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20181-2953
Mailing Address - Country:US
Mailing Address - Phone:571-408-9139
Mailing Address - Fax:
Practice Address - Street 1:14610 SULKY RUN CT
Practice Address - Street 2:
Practice Address - City:NOKESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20181-2953
Practice Address - Country:US
Practice Address - Phone:571-408-9139
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1043570294207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty