Provider Demographics
NPI:1962103747
Name:OPTIMAL SLEEP AND WEIGHT LOSS CLINIC, PLLC
Entity type:Organization
Organization Name:OPTIMAL SLEEP AND WEIGHT LOSS CLINIC, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PASCAL
Authorized Official - Middle Name:
Authorized Official - Last Name:NGONGMON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-955-5355
Mailing Address - Street 1:13 CARROLL DR
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-5340
Mailing Address - Country:US
Mailing Address - Phone:703-955-5355
Mailing Address - Fax:
Practice Address - Street 1:13000 HARBOR CENTER DR STE 202
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2847
Practice Address - Country:US
Practice Address - Phone:240-353-0663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-17
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder DiagnosticGroup - Multi-Specialty