Healthcare Provider Details

I. General information

NPI: 1841489531
Provider Name (Legal Business Name): SPINE AND SPORT REHAB CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 03/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4656D KING ST
ALEXANDRIA VA
22302-1215
US

IV. Provider business mailing address

4656D KING ST
ALEXANDRIA VA
22302-1215
US

V. Phone/Fax

Practice location:
  • Phone: 703-998-0600
  • Fax: 703-998-0333
Mailing address:
  • Phone: 703-998-0600
  • Fax: 703-998-0333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number0104556081
License Number StateVA

VIII. Authorized Official

Name: DR. NATHAN LE
Title or Position: PRESIDENT
Credential: DC
Phone: 703-998-0600