Healthcare Provider Details

I. General information

NPI: 1790865285
Provider Name (Legal Business Name): PHILIP PETER CONNOLLY D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 11/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7025C MANCHESTER BLVD
ALEXANDRIA VA
22310-3227
US

IV. Provider business mailing address

7025C MANCHESTER BLVD
ALEXANDRIA VA
22310-3227
US

V. Phone/Fax

Practice location:
  • Phone: 703-719-7302
  • Fax: 703-719-9462
Mailing address:
  • Phone: 703-719-7302
  • Fax: 703-719-9462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number0104001006
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: