Organization
DIETETIC CONSULTANTS OF NORTHERN VIRGINIA, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BONITA LILLIE RD, LD (PRESIDENT)
(703) 879-5160
Entity
Organization
Contact information
Practice address
2121 EISENHOWER AVE, SUITE 200, ALEXANDRIA, VA 22314-4698
(703) 519-0901
(703) 519-0902
Mailing address
5412 CASTLE BAR LN, ALEXANDRIA, VA 22315-5519
(703) 879-5160
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
2004009119
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
G02785
MEDICARE PTAN
—
Enumeration date
11/07/2007
Last updated
09/18/2008
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