Provider Demographics
NPI:1912250663
Name:FAMILY HEALTH CENTER PLLC
Entity Type:Organization
Organization Name:FAMILY HEALTH CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MEHRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAJAVI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-264-0888
Mailing Address - Street 1:P.O. BOX 4458
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20177
Mailing Address - Country:US
Mailing Address - Phone:703-895-2237
Mailing Address - Fax:304-264-0878
Practice Address - Street 1:1004 SUSHRUTA DR STE C
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-8801
Practice Address - Country:US
Practice Address - Phone:304-264-0888
Practice Address - Fax:304-264-0878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-18
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22758261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810026141Medicaid
WVC487OtherMEDICARE PTAN