Provider Demographics
NPI:1174841324
Name:CLINICA OF VIRGINIA LLC
Entity type:Organization
Organization Name:CLINICA OF VIRGINIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:WOODROW
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BOYER
Authorized Official - Suffix:
Authorized Official - Credentials:EGM
Authorized Official - Phone:863-614-0371
Mailing Address - Street 1:1600 TYSONS BLVD
Mailing Address - Street 2:8TH FLOOR
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-4865
Mailing Address - Country:US
Mailing Address - Phone:703-245-8513
Mailing Address - Fax:703-245-3001
Practice Address - Street 1:10560 MAIN ST
Practice Address - Street 2:#215
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-7182
Practice Address - Country:US
Practice Address - Phone:571-432-0700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty