| Vita Family Medicine And Medspa Llc | |
|
540 Fort Evans Rd Suite 204 Leesburg VA 20176-3379 | |
| (703) 737-3500 | |
| (703) 737-3550 |
| Full Name | Vita Family Medicine And Medspa Llc |
|---|---|
| Speciality | Family Medicine |
| Location | 540 Fort Evans Rd, Leesburg, Virginia |
| Authorized Official Name and Position | Jennifer Boudreau (OWNER/DOCTOR) |
| Authorized Official Contact | 7178058264 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Vita Family Medicine And Medspa Llc 540 Fort Evans Rd Suite 204 Leesburg VA 20176-3379 Ph: (703) 737-3500 | Vita Family Medicine And Medspa Llc 540 Fort Evans Rd Suite 204 Leesburg VA 20176-3379 Ph: (703) 737-3500 |
| NPI Number | 1730532359 |
|---|---|
| Provider Enumeration Date | 07/19/2016 |
| Last Update Date | 10/13/2016 |
| Medicare PECOS PAC ID | 4688962442 |
|---|---|
| Medicare Enrollment ID | O20161011000603 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1730532359 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (Virginia) | Primary |
| 261QP2300X | Clinic/center - Primary Care | 0101258315 (Virginia) | Secondary |
| Provider Name | Jennifer B Boudreau |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1811216021 PECOS PAC ID: 2466696448 Enrollment ID: I20150908002772 |
| Provider Name | Erica M Shackelford |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1902375694 PECOS PAC ID: 0244578060 Enrollment ID: I20190220001649 |
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