Provider Demographics
NPI:1497808679
Name:INOVA KELLAR CENTER
Entity Type:Organization
Organization Name:INOVA KELLAR CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:LEICHTWEIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:703-218-8500
Mailing Address - Street 1:PO BOX 1110
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22038-1110
Mailing Address - Country:US
Mailing Address - Phone:703-218-8500
Mailing Address - Fax:703-359-0463
Practice Address - Street 1:11204 WAPLES MILL RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6048
Practice Address - Country:US
Practice Address - Phone:703-218-8500
Practice Address - Fax:703-359-0463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA033261QM0855X
261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4943902Medicaid