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Organization
TACKLE MANAGEMENT CORPORATION
Active
Organization
TACKLE MANAGEMENT CORPORATION
Active
Other names
BULL RUN FOOT CLINIC
Organization subpart
No
Provider details
NPI number
Authorized official
MISS THERESA LYNN COATES (PRACTICE ADMINISTRATOR)
(703) 368-1800
Entity
Organization
Contact information
Practice address
8637 MATHIS AVE, MANASSAS, VA 20110-5270
(703) 335-6890
Mailing address
8637 MATHIS AVE, MANASSAS, VA 20110-5270
(703) 335-6890
Taxonomy
Speciality
Code
Description
License number
State
213ES0103X
Foot & Ankle Surgery Podiatrist
Primary
—
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
296209
ANTHEM
VA
Enumeration date
11/13/2007
Last updated
11/13/2007
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