Healthcare Provider Details

I. General information

NPI: 1174735856
Provider Name (Legal Business Name): SPORT AND SPINE REHAB OF FAIRFAX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10807 MAIN STREET
FAIRFAX VA
22303
US

IV. Provider business mailing address

11418 LIVINGSTON ROAD
FT. WASHINGTON MD
20744
US

V. Phone/Fax

Practice location:
  • Phone: 703-890-2222
  • Fax:
Mailing address:
  • Phone: 240-766-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. JAY GREENSTEIN
Title or Position: CEO
Credential: DC
Phone: 240-766-0300