MEDICARE: CORE WELLNESS & PHYSICAL THERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center	2305205043	VA

General Provider Information

NPI Number	:	1871850164
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORE WELLNESS & PHYSICAL THERAPY, LLC

Provider Business Mailing Address
First Line	:	2212 MOUNT VERNON AVE
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22301-1356
Country	:	US
Telephone Number	:	571-403-2673
Fax Number	:	571-366-2052

Provider Business Practice Location Address
First Line	:	2212 MOUNT VERNON AVE
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22301-1356
Country	:	US
Telephone Number	:	571-403-2673
Fax Number	:	571-366-2052

Authorized Official
Title or Position	:	OWNER, FOUNDER, LEAD PT
Name	:	DR. ELIZABETH POLIS
Credential	:	PT, DPT
Telephone Number	:	571-309-3048

Provider Enumeration Date	:	04/12/2012
Last Update Date	:	03/04/2014

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