Healthcare Provider Details

I. General information

NPI: 1346297116
Provider Name (Legal Business Name): PEPPERWOLF SPINAL CARE INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 03/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2136 GALLOWS ROAD SUITE A
DUNN LORING VA
22027-1036
US

IV. Provider business mailing address

2136 GALLOWS ROAD SUITE A
DUNN LORING VA
22027-1036
US

V. Phone/Fax

Practice location:
  • Phone: 703-204-2320
  • Fax: 703-204-1618
Mailing address:
  • Phone: 703-204-2320
  • Fax: 703-204-1618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1747
License Number StateVA

VIII. Authorized Official

Name: DR. BRAD A WOLF
Title or Position: PRESIDENT
Credential: D.C.
Phone: 703-204-2320