Healthcare Provider Details

I. General information

NPI: 1639194152
Provider Name (Legal Business Name): ALEXANDRIA SPORTS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 02/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 WESTPARK DR SUITE 150
MC LEAN VA
22102-3114
US

IV. Provider business mailing address

PO BOX 1245
INDIANA PA
15701-5245
US

V. Phone/Fax

Practice location:
  • Phone: 703-556-8477
  • Fax: 703-556-8486
Mailing address:
  • Phone: 724-465-3496
  • Fax: 215-413-4682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. JAYNE FLECK POOL
Title or Position: CHIEF COMPLIANCE OFFICER
Credential:
Phone: 469-467-8705