Provider Demographics
NPI:1568242519
Name:MSRC ONE, LLC
Entity Type:Organization
Organization Name:MSRC ONE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEHORTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-774-9910
Mailing Address - Street 1:18300 QUANTICO GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:TRIANGLE
Mailing Address - State:VA
Mailing Address - Zip Code:22172-1798
Mailing Address - Country:US
Mailing Address - Phone:571-774-9910
Mailing Address - Fax:
Practice Address - Street 1:18300 QUANTICO GATEWAY DR STE 202
Practice Address - Street 2:
Practice Address - City:TRIANGLE
Practice Address - State:VA
Practice Address - Zip Code:22172-1798
Practice Address - Country:US
Practice Address - Phone:571-774-9910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MSRC ONE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-10-05
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Single Specialty