Healthcare Provider Details

I. General information

NPI: 1669656971
Provider Name (Legal Business Name): PAINREHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2007
Last Update Date: 02/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2823 DUKE ST
ALEXANDRIA VA
22314-4512
US

IV. Provider business mailing address

2823 DUKE ST
ALEXANDRIA VA
22314-4512
US

V. Phone/Fax

Practice location:
  • Phone: 703-823-0063
  • Fax: 702-823-0644
Mailing address:
  • Phone: 703-823-0063
  • Fax: 702-823-0644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number01-1232198
License Number StateVA

VIII. Authorized Official

Name: EDITH QUIACHON BAUTISTA-QUINT
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 703-823-0063