Healthcare Provider Details

I. General information

NPI: 1336510395
Provider Name (Legal Business Name): RIVERSIDE CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2015
Last Update Date: 10/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205A THE STRAND
ALEXANDRIA VA
22314-3367
US

IV. Provider business mailing address

205A THE STRAND
ALEXANDRIA VA
22314-3367
US

V. Phone/Fax

Practice location:
  • Phone: 703-739-0500
  • Fax: 866-545-1147
Mailing address:
  • Phone: 703-739-0500
  • Fax: 866-545-1147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number0104001959
License Number StateVA

VIII. Authorized Official

Name: DR. WALEED MAHMOUD ABUL-HAWA
Title or Position: PRACTICE OWNER
Credential: D.C.
Phone: 703-739-0500