Provider Demographics
NPI:1497079073
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:
Authorized Official - Last Name:BOCCONE
Authorized Official - Suffix:
Authorized Official - Credentials:JD, LLM
Authorized Official - Phone:703-378-3854
Mailing Address - Street 1:4200 LAFAYETTE CENTER DR
Mailing Address - Street 2:STE R
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-1241
Mailing Address - Country:US
Mailing Address - Phone:703-378-3854
Mailing Address - Fax:703-378-4909
Practice Address - Street 1:4200 LAFAYETTE CENTER DR
Practice Address - Street 2:STE R
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1241
Practice Address - Country:US
Practice Address - Phone:703-378-3854
Practice Address - Fax:703-378-4909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-25
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty