Healthcare Provider Details

I. General information

NPI: 1538476734
Provider Name (Legal Business Name): BRISTOW PHYSICAL THERAPY & CHIROPRACTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2010
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10402 BRISTOW CENTER DR.
BRISTOW VA
20136-2202
US

IV. Provider business mailing address

10402 BRISTOW CENTER DR.
BRISTOW VA
20136-2202
US

V. Phone/Fax

Practice location:
  • Phone: 703-686-4010
  • Fax: 703-686-4011
Mailing address:
  • Phone: 703-686-4010
  • Fax: 703-686-4011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License Number0119003872
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104001138
License Number StateVA

VIII. Authorized Official

Name: DR. HOWARD RICHARD VAN NOSTRAND
Title or Position: CLINIC DIRECTOR
Credential: DC
Phone: 703-686-4010