Provider Demographics
NPI:1932479516
Name:WOODBRIDGE CARDIOVASCULAR CENTER
Entity Type:Organization
Organization Name:WOODBRIDGE CARDIOVASCULAR CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PRACHAK
Authorized Official - Middle Name:
Authorized Official - Last Name:SIRIPRAKORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-491-6780
Mailing Address - Street 1:14904 JEFFERSON DAVIS HWY
Mailing Address - Street 2:SUITE101
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3908
Mailing Address - Country:US
Mailing Address - Phone:703-491-6781
Mailing Address - Fax:703-491-6782
Practice Address - Street 1:14904 JEFFERSON DAVIS HWY
Practice Address - Street 2:SUITE101
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3908
Practice Address - Country:US
Practice Address - Phone:703-491-6781
Practice Address - Fax:703-491-6782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA99409418291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA108509OtherINTERSOCIETAL COMMISSION FOR THE ACCREDITATION OF NUCLEAR MEDICINE LABORATORIES