Provider Demographics
NPI:1477934727
Name:POTOMAC HEALTHCARE SOLUTIONS, LLC
Entity type:Organization
Organization Name:POTOMAC HEALTHCARE SOLUTIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAPHNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-498-2773
Mailing Address - Street 1:1549 OLD BRIDGE RD STE 201
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-2737
Mailing Address - Country:US
Mailing Address - Phone:703-498-2773
Mailing Address - Fax:703-542-1772
Practice Address - Street 1:1549 OLD BRIDGE RD STE 201
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2737
Practice Address - Country:US
Practice Address - Phone:703-498-2773
Practice Address - Fax:703-542-1772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-12
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAS4081867291U00000X, 261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No291U00000XLaboratoriesClinical Medical Laboratory