Provider Demographics
NPI:1407079155
Name:NORTHERN VIRGINIA EYE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:NORTHERN VIRGINIA EYE SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:RICH
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:703-534-3900
Mailing Address - Street 1:2710 PROSPERITY AVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4320
Mailing Address - Country:US
Mailing Address - Phone:703-289-1290
Mailing Address - Fax:703-289-1298
Practice Address - Street 1:2710 PROSPERITY AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4320
Practice Address - Country:US
Practice Address - Phone:703-289-1290
Practice Address - Fax:703-289-1298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAOH712261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA130731Medicare PIN