Healthcare Provider Details

I. General information

NPI: 1295460863
Provider Name (Legal Business Name): SOLANO SPINE & SPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2022
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 W BROAD ST STE 620
FALLS CHURCH VA
22046-3133
US

IV. Provider business mailing address

803 W BROAD ST STE 620
FALLS CHURCH VA
22046-3133
US

V. Phone/Fax

Practice location:
  • Phone: 703-536-4366
  • Fax: 703-536-7933
Mailing address:
  • Phone: 703-536-4366
  • Fax: 703-536-7933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: RAYMOND SOLANO
Title or Position: OWNER
Credential:
Phone: 703-536-4366