Healthcare Provider Details

I. General information

NPI: 1114764107
Provider Name (Legal Business Name): SPINE AND SPORTS REGENERATIVE MEDICINE INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2024
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10721 MAIN ST STE 304
FAIRFAX VA
22030-6902
US

IV. Provider business mailing address

10721 MAIN ST STE 304
FAIRFAX VA
22030-6902
US

V. Phone/Fax

Practice location:
  • Phone: 703-349-4205
  • Fax: 703-349-4205
Mailing address:
  • Phone: 703-349-4205
  • Fax: 703-349-4205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID KIM
Title or Position: CEO
Credential: MD
Phone: 703-349-4205