Provider Demographics
NPI:1669804159
Name:VIP IMED CENTER
Entity type:Organization
Organization Name:VIP IMED CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BORISOVNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-207-4646
Mailing Address - Street 1:8303 ARLINGTON BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2903
Mailing Address - Country:US
Mailing Address - Phone:703-207-4646
Mailing Address - Fax:703-563-7467
Practice Address - Street 1:8303 ARLINGTON BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4645
Practice Address - Country:US
Practice Address - Phone:703-207-4646
Practice Address - Fax:703-563-7467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-06
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101055521208D00000X
VA0101255440208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty