Healthcare Provider Details

I. General information

NPI: 1275985970
Provider Name (Legal Business Name): SPINE AND PAIN CLINIC OF NORTH AMERICA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2016
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 FAIR RIDGE DR SUITE 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: 301-873-9596
  • Fax: 703-520-7269
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
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number0101233975
License Number StateVA

VIII. Authorized Official

Name: FARAH ZIA
Title or Position: OWNER
Credential:
Phone: 703-520-1031