Provider Demographics
NPI:1356975494
Name:STAUNTON MC 1 LLC
Entity type:Organization
Organization Name:STAUNTON MC 1 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:YURY
Authorized Official - Middle Name:
Authorized Official - Last Name:YAKUBCHYK
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:786-210-8200
Mailing Address - Street 1:1775 TYSONS BLVD FL 5
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-4285
Mailing Address - Country:US
Mailing Address - Phone:786-210-8200
Mailing Address - Fax:
Practice Address - Street 1:1775 TYSONS BLVD FL 5
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-4285
Practice Address - Country:US
Practice Address - Phone:786-210-8200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty