Provider Demographics
NPI:1831379882
Name:DIETETIC CONSULTANTS OF NORTHERN VIRGINIA, LLC
Entity type:Organization
Organization Name:DIETETIC CONSULTANTS OF NORTHERN VIRGINIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BONITA
Authorized Official - Middle Name:
Authorized Official - Last Name:LILLIE
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LD
Authorized Official - Phone:703-879-5160
Mailing Address - Street 1:5412 CASTLE BAR LN
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22315-5519
Mailing Address - Country:US
Mailing Address - Phone:703-879-5160
Mailing Address - Fax:
Practice Address - Street 1:2121 EISENHOWER AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-4698
Practice Address - Country:US
Practice Address - Phone:703-519-0901
Practice Address - Fax:703-519-0902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004009119133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G02785OtherMEDICARE PTAN