Provider Demographics
NPI:1982859484
Name:CHILDREN'S HEALTH CARE CENTER OF NOVA
Entity Type:Organization
Organization Name:CHILDREN'S HEALTH CARE CENTER OF NOVA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:WALLACE
Authorized Official - Last Name:MCEACHERN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FAAP
Authorized Official - Phone:703-392-5437
Mailing Address - Street 1:9001 DIGGES RD STE 106
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4414
Mailing Address - Country:US
Mailing Address - Phone:703-392-5437
Mailing Address - Fax:
Practice Address - Street 1:9001 DIGGES RD STE 106
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4414
Practice Address - Country:US
Practice Address - Phone:703-392-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-25
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051497208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006724264Medicaid