Provider Demographics
NPI:1467823575
Name:FAIRFAX CLINIC LLC
Entity Type:Organization
Organization Name:FAIRFAX CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VIET
Authorized Official - Middle Name:HUU
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:301-613-8124
Mailing Address - Street 1:6408 SEVEN CORNERS PL STE C
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22044-2011
Mailing Address - Country:US
Mailing Address - Phone:703-532-1909
Mailing Address - Fax:703-532-5868
Practice Address - Street 1:6408 SEVEN CORNERS PL STE C
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22044-2011
Practice Address - Country:US
Practice Address - Phone:703-532-1909
Practice Address - Fax:703-532-5868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102204088261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center