Provider Demographics
NPI:1770914939
Name:GREATER PRINCE WILLIAM AREA COMMUNITY HEALTH CENTER INC
Entity type:Organization
Organization Name:GREATER PRINCE WILLIAM AREA COMMUNITY HEALTH CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:BARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-670-8858
Mailing Address - Street 1:4379 RIDGEWOOD CENTER DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-8322
Mailing Address - Country:US
Mailing Address - Phone:703-680-7950
Mailing Address - Fax:703-680-7953
Practice Address - Street 1:9705 LIBERIA AVE
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-1743
Practice Address - Country:US
Practice Address - Phone:703-680-7950
Practice Address - Fax:703-680-7953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-12
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1770914939Medicaid
VA1770914939Medicaid
C10201Medicare PIN