Healthcare Provider Details

I. General information

NPI: 1992730469
Provider Name (Legal Business Name): BACK IN MOTION PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9447B LORTON MARKET ST SUITE 250
LORTON VA
22079-1963
US

IV. Provider business mailing address

9447B LORTON MARKET ST SUITE 250
LORTON VA
22079-1963
US

V. Phone/Fax

Practice location:
  • Phone: 703-372-5716
  • Fax: 703-372-5718
Mailing address:
  • Phone: 703-372-5716
  • Fax: 703-372-5718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305003310
License Number StateVA

VIII. Authorized Official

Name: MRS. MARY P NALLS
Title or Position: PRESIDENT
Credential: MPT
Phone: 703-690-2650