| Evergreen Terrace Building | |
|
9705 Liberia Ave Manassas VA 20110-1743 | |
| (703) 680-7950 | |
| (703) 680-7953 |
| Full Name | Evergreen Terrace Building |
|---|---|
| Speciality | Clinic/Center |
| Location | 9705 Liberia Ave, Manassas, Virginia |
| Authorized Official Name and Position | George Barker (CEO) |
| Authorized Official Contact | 7036708858 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Evergreen Terrace Building 4379 Ridgewood Center Dr Suite 102 Woodbridge VA 22192-8322 Ph: (703) 680-7950 | Evergreen Terrace Building 9705 Liberia Ave Manassas VA 20110-1743 Ph: (703) 680-7950 |
| NPI Number | 1770914939 |
|---|---|
| Provider Enumeration Date | 12/12/2013 |
| Last Update Date | 10/29/2015 |
| Medicare PECOS PAC ID | 9436258209 |
|---|---|
| Medicare Enrollment ID | O20140327000698 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1770914939 | NPI | - | NPPES |
| 1770914939 | Medicaid | VA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |
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