Provider Demographics
NPI:1467105569
Name:MOA MID-ATLANTIC CHANTILLY PC
Entity Type:Organization
Organization Name:MOA MID-ATLANTIC CHANTILLY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:703-830-6380
Mailing Address - Street 1:44365 PREMIER PLZ STE 210
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-5058
Mailing Address - Country:US
Mailing Address - Phone:703-830-6380
Mailing Address - Fax:703-263-2441
Practice Address - Street 1:3910 CENTREVILLE RD STE 102
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-3280
Practice Address - Country:US
Practice Address - Phone:703-830-6380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty