Healthcare Provider Details

I. General information

NPI: 1720714934
Provider Name (Legal Business Name): JUSTIN MEADE GRIGGS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2022
Last Update Date: 07/30/2022
Certification Date: 07/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6858 OLD DOMINION DR STE 200
MC LEAN VA
22101-3832
US

IV. Provider business mailing address

4040 HEATHERSTONE CT
FAIRFAX VA
22030-7452
US

V. Phone/Fax

Practice location:
  • Phone: 571-215-8377
  • Fax:
Mailing address:
  • Phone: 571-215-8377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306605957
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: