Provider Demographics
NPI:1316161151
Name:FAIRFAX MEDICAL CENTER OPTICIAN INC.
Entity type:Organization
Organization Name:FAIRFAX MEDICAL CENTER OPTICIAN INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:FERRARO
Authorized Official - Suffix:SR
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:703-978-5170
Mailing Address - Street 1:10721 MAIN ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6959
Mailing Address - Country:US
Mailing Address - Phone:703-273-4237
Mailing Address - Fax:703-273-1207
Practice Address - Street 1:10721 MAIN ST
Practice Address - Street 2:SUITE 105
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6959
Practice Address - Country:US
Practice Address - Phone:703-273-4237
Practice Address - Fax:703-273-1207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA103372156FX1800X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Not Answered332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0221270001Medicare ID - Type Unspecified