Provider Demographics
NPI:1659812832
Name:NORTHERN VIRGINIA LABORATORY
Entity Type:Organization
Organization Name:NORTHERN VIRGINIA LABORATORY
Other - Org Name:NORTHERN VIRGINIA LABORATORY LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:B
Authorized Official - Last Name:MADDUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-207-7072
Mailing Address - Street 1:8422 GIRVAN CT
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109
Mailing Address - Country:US
Mailing Address - Phone:703-207-7072
Mailing Address - Fax:703-207-7074
Practice Address - Street 1:4660 KENMORE AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1313
Practice Address - Country:US
Practice Address - Phone:703-207-7072
Practice Address - Fax:703-207-7074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory