Healthcare Provider Details

I. General information

NPI: 1376116343
Provider Name (Legal Business Name): ATLANTIC KNEE RESTORATION & REGENERATIVE MEDICINE - RESTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 ELDEN ST STE 10
HERNDON VA
20170-4826
US

IV. Provider business mailing address

7481 RIGHT FLANK RD STE 100
MECHANICSVILLE VA
23116-3838
US

V. Phone/Fax

Practice location:
  • Phone: 703-854-1432
  • Fax:
Mailing address:
  • Phone: 804-877-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT CRITTENDEN III
Title or Position: OWNER
Credential:
Phone: 256-302-2228