Provider Demographics
NPI:1558865899
Name:PREMIER BIRTH CENTER CHANTILLY LLC
Entity Type:Organization
Organization Name:PREMIER BIRTH CENTER CHANTILLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:PEKIN
Authorized Official - Suffix:
Authorized Official - Credentials:CPM
Authorized Official - Phone:240-422-3889
Mailing Address - Street 1:4200A TECHNOLOGY CT
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-1214
Mailing Address - Country:US
Mailing Address - Phone:240-422-3889
Mailing Address - Fax:
Practice Address - Street 1:4200A TECHNOLOGY CT
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1214
Practice Address - Country:US
Practice Address - Phone:240-422-3889
Practice Address - Fax:866-611-3615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0129000052176B00000X
261QB0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthing
No176B00000XOther Service ProvidersMidwifeGroup - Single Specialty