Provider Demographics
NPI:1376853341
Name:CHANTILLY SPECIALISTS, LTD. OF VIRGINIA
Entity Type:Organization
Organization Name:CHANTILLY SPECIALISTS, LTD. OF VIRGINIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:P
Authorized Official - Last Name:BOCCONE
Authorized Official - Suffix:
Authorized Official - Credentials:JD, LLM
Authorized Official - Phone:571-251-5471
Mailing Address - Street 1:14121 PARKE LONG CT
Mailing Address - Street 2:SUITE 112
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-1647
Mailing Address - Country:US
Mailing Address - Phone:571-251-5471
Mailing Address - Fax:703-378-4909
Practice Address - Street 1:14121 PARKE LONG CT
Practice Address - Street 2:SUITE 112
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1647
Practice Address - Country:US
Practice Address - Phone:571-251-5471
Practice Address - Fax:703-378-4909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-08
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA49D2006729291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory