Provider Demographics
NPI:1295124782
Name:GYNECOLOGY & WELLNESS CENTER LLC
Entity type:Organization
Organization Name:GYNECOLOGY & WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CECILIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-955-4430
Mailing Address - Street 1:8292 OLD COURTHOUSE RD STE C
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3864
Mailing Address - Country:US
Mailing Address - Phone:703-448-6070
Mailing Address - Fax:703-448-1049
Practice Address - Street 1:8292 OLD COURTHOUSE RD STE C
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3864
Practice Address - Country:US
Practice Address - Phone:703-448-6070
Practice Address - Fax:703-448-1049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-21
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236981207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010328381Medicaid
VA010328381Medicaid
VAI63780Medicare UPIN