Provider Demographics
NPI:1548553068
Name:PREM P. MANCHANDA MD, PC
Entity type:Organization
Organization Name:PREM P. MANCHANDA MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PREM
Authorized Official - Middle Name:
Authorized Official - Last Name:MANCHANDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-981-4865
Mailing Address - Street 1:4100 ORCHARD DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-1021
Mailing Address - Country:US
Mailing Address - Phone:703-981-4865
Mailing Address - Fax:
Practice Address - Street 1:4660 KENMORE AVE
Practice Address - Street 2:220
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1313
Practice Address - Country:US
Practice Address - Phone:703-981-4865
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-17
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057630261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care