Provider Demographics
NPI:1750612495
Name:MEDICAL MANAGEMENT OF VA LLC
Entity type:Organization
Organization Name:MEDICAL MANAGEMENT OF VA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:EWENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-587-7771
Mailing Address - Street 1:11230 WAPLES MILL RD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6087
Mailing Address - Country:US
Mailing Address - Phone:954-587-7771
Mailing Address - Fax:954-208-5770
Practice Address - Street 1:10640 MAIN ST
Practice Address - Street 2:SUITE 300
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-3821
Practice Address - Country:US
Practice Address - Phone:954-587-7771
Practice Address - Fax:954-208-5770
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRIDGING THE GAPS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA42902001324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility