Provider Demographics
NPI:1598016545
Name:TAVAZON PC
Entity type:Organization
Organization Name:TAVAZON PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-651-3980
Mailing Address - Street 1:46179 WESTLAKE DRIVE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20165
Mailing Address - Country:US
Mailing Address - Phone:571-455-8006
Mailing Address - Fax:
Practice Address - Street 1:2960 SLEEPY HOLLOW RD
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22044
Practice Address - Country:US
Practice Address - Phone:571-455-8006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-29
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101238065305R00000X, 305S00000X, 283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
No305R00000XManaged Care OrganizationsPreferred Provider Organization
No305S00000XManaged Care OrganizationsPoint of Service