Healthcare Provider Details

I. General information

NPI: 1023921756
Provider Name (Legal Business Name): VIDA SPINE AND PAIN CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 FAIR RIDGE DR STE 202
FAIRFAX VA
22033-2917
US

IV. Provider business mailing address

4001 FAIR RIDGE DR STE 202
FAIRFAX VA
22033-2917
US

V. Phone/Fax

Practice location:
  • Phone: 703-520-1031
  • Fax: 701-520-7269
Mailing address:
  • Phone: 703-520-1031
  • Fax: 703-520-7269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: RAMON C GO
Title or Position: MD/CEO
Credential: MD
Phone: 703-520-1031