Healthcare Provider Details

I. General information

NPI: 1598861395
Provider Name (Legal Business Name): VIRGINIA CENTER FOR SPINE & SPORTS THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 09/22/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 WATERFORD LAKE DR SUITE 103
MIDLOTHIAN VA
23112-3994
US

IV. Provider business mailing address

2820 WATERFORD LAKE DR STE 103
MIDLOTHIAN VA
23112-3994
US

V. Phone/Fax

Practice location:
  • Phone: 804-249-8277
  • Fax: 804-249-9690
Mailing address:
  • Phone: 804-249-8277
  • Fax: 804-249-9690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARYANN THERESA DOMINGUEZ
Title or Position: PRACTICE ADMINISTRATOR
Credential: PT
Phone: 804-249-8277