Provider Demographics
NPI:1922024041
Name:PET OF RESTON, LP
Entity Type:Organization
Organization Name:PET OF RESTON, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:ATKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, MIS, CPHIMS
Authorized Official - Phone:703-726-1201
Mailing Address - Street 1:P.O. BOX 207421
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7421
Mailing Address - Country:US
Mailing Address - Phone:703-726-1201
Mailing Address - Fax:703-726-1053
Practice Address - Street 1:1830 TOWN CENTER DRIVE
Practice Address - Street 2:SUITE 105
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3237
Practice Address - Country:US
Practice Address - Phone:571-601-2901
Practice Address - Fax:571-577-4142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG01960Medicare ID - Type Unspecified