Healthcare Provider Details

I. General information

NPI: 1750500401
Provider Name (Legal Business Name): J. ARDENIA GAINES NCTMB, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 WARRENTON RD
FREDERICKSBURG VA
22406-1028
US

IV. Provider business mailing address

676 WARRENTON RD
FREDERICKSBURG VA
22406-1028
US

V. Phone/Fax

Practice location:
  • Phone: 540-899-1773
  • Fax:
Mailing address:
  • Phone: 540-899-1773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License Number0019006578
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: