Healthcare Provider Details

I. General information

NPI: 1962058040
Provider Name (Legal Business Name): LUIS CARLOS MEJIA PT,DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2019
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S. WASHINGTON ST. STE A
FALLS CHURCH VA
22046
US

IV. Provider business mailing address

350 NEW FIDELITY CT
GARNER NC
27529-2665
US

V. Phone/Fax

Practice location:
  • Phone: 703-992-7255
  • Fax:
Mailing address:
  • Phone: 919-373-2919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1315625
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP010526T
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: