Healthcare Provider Details

I. General information

NPI: 1760623201
Provider Name (Legal Business Name): SKYLINE WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2009
Last Update Date: 04/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4218 KING ST
ALEXANDRIA VA
22302-1507
US

IV. Provider business mailing address

4218 KING ST
ALEXANDRIA VA
22302-1507
US

V. Phone/Fax

Practice location:
  • Phone: 703-879-5144
  • Fax: 703-879-5860
Mailing address:
  • Phone: 703-879-5144
  • Fax: 703-879-5860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104556267
License Number StateVA

VIII. Authorized Official

Name: DR. WILFRIED F SANSFAUTE
Title or Position: CHIROPRACTOR
Credential: D.C.
Phone: 703-873-5144