Healthcare Provider Details

I. General information

NPI: 1265820484
Provider Name (Legal Business Name): DYNAMIC REHAB & SPINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2014
Last Update Date: 12/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2380 PLANK RD
FREDERICKSBURG VA
22401-4927
US

IV. Provider business mailing address

2380 PLANK RD
FREDERICKSBURG VA
22401-4927
US

V. Phone/Fax

Practice location:
  • Phone: 540-373-1303
  • Fax: 540-373-6061
Mailing address:
  • Phone: 540-373-1303
  • Fax: 540-373-6061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number0104557195
License Number StateVA

VIII. Authorized Official

Name: DR. BURGANDI COLLINS
Title or Position: CHIROPRACTOR
Credential: DC
Phone: 757-927-9851