Provider Demographics
NPI:1629325758
Name:LOUDOUN COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:LOUDOUN COMMUNITY HEALTH CENTER
Other - Org Name:HEALTHWORKS FOR NORTHERN VIRGINIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMESON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:703-840-4704
Mailing Address - Street 1:163 FORT EVANS RD NE
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-4420
Mailing Address - Country:US
Mailing Address - Phone:703-840-4707
Mailing Address - Fax:703-771-4120
Practice Address - Street 1:1141 ELDEN STREET
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-5573
Practice Address - Country:US
Practice Address - Phone:703-481-8160
Practice Address - Fax:703-435-6752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-08
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1629325758Medicaid
VAC10139Medicare PIN
VA1629325758Medicaid