Healthcare Provider Details

I. General information

NPI: 1457607889
Provider Name (Legal Business Name): KINETA REHAB SOLUTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2012
Last Update Date: 08/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 S GORDON ST
ALEXANDRIA VA
22304-4929
US

IV. Provider business mailing address

53 S GORDON ST
ALEXANDRIA VA
22304-4929
US

V. Phone/Fax

Practice location:
  • Phone: 703-587-1907
  • Fax: 571-970-6125
Mailing address:
  • Phone: 703-587-1907
  • Fax: 571-970-6125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number2306601555
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number0119003001
License Number StateVA

VIII. Authorized Official

Name: MRS. JOYCE C JEFFERSON
Title or Position: OWNER
Credential: LPTA
Phone: 703-587-1907