Provider Demographics
NPI:1760661391
Name:FAIRFAX CONVENIENT CARE LLC
Entity Type:Organization
Organization Name:FAIRFAX CONVENIENT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUDY
Authorized Official - Middle Name:H
Authorized Official - Last Name:JUBURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-849-0900
Mailing Address - Street 1:8301 ARLINGTON BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2902
Mailing Address - Country:US
Mailing Address - Phone:703-849-0900
Mailing Address - Fax:703-208-7444
Practice Address - Street 1:8301 ARLINGTON BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2902
Practice Address - Country:US
Practice Address - Phone:703-849-0900
Practice Address - Fax:703-208-7444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCDN6020Medicare PIN
DCG02804Medicare PIN