Provider Demographics
NPI:1205445491
Name:FAIRFAX MEDICAL LAB LLC
Entity type:Organization
Organization Name:FAIRFAX MEDICAL LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASRA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:571-577-5556
Mailing Address - Street 1:4221 WALNEY RD STE 401A
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-2987
Mailing Address - Country:US
Mailing Address - Phone:571-577-5556
Mailing Address - Fax:
Practice Address - Street 1:4221 WALNEY RD STE 401A
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-2987
Practice Address - Country:US
Practice Address - Phone:571-577-5556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-24
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory