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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