Provider Demographics
NPI:1578979886
Name:KENT VILLAGE MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:KENT VILLAGE MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FEDERICO
Authorized Official - Middle Name:CARLOS
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-715-9700
Mailing Address - Street 1:3700 JOSEPH SIEWICK DR
Mailing Address - Street 2:SUITE 401
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1744
Mailing Address - Country:US
Mailing Address - Phone:703-715-9700
Mailing Address - Fax:703-715-0202
Practice Address - Street 1:112 KENT VILLAGE SQ
Practice Address - Street 2:
Practice Address - City:MANASSAS PARK
Practice Address - State:VA
Practice Address - Zip Code:20111-4155
Practice Address - Country:US
Practice Address - Phone:703-715-9700
Practice Address - Fax:703-715-0202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101028651261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCC62035Medicare UPIN