Provider Demographics
NPI:1356943278
Name:FAIRFAX RADIOLOGY BREAST CENTER OF LOUDOUN
Entity type:Organization
Organization Name:FAIRFAX RADIOLOGY BREAST CENTER OF LOUDOUN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-698-4444
Mailing Address - Street 1:2722 MERRILEE DR STE 230
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4400
Mailing Address - Country:US
Mailing Address - Phone:703-698-4444
Mailing Address - Fax:703-698-2176
Practice Address - Street 1:19465 DEERFIELD AVE STE 105
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-1702
Practice Address - Country:US
Practice Address - Phone:703-788-8426
Practice Address - Fax:571-382-6587
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IFRC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography