Healthcare Provider Details

I. General information

NPI: 1053427740
Provider Name (Legal Business Name): PENINSULA PAIN AND REHABILITATION CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11015 WARWICK BLVD
NEWPORT NEWS VA
23601-3225
US

IV. Provider business mailing address

11015 WARWICK BLVD
NEWPORT NEWS VA
23601-3225
US

V. Phone/Fax

Practice location:
  • Phone: 757-591-7291
  • Fax: 757-591-2125
Mailing address:
  • Phone: 757-591-7291
  • Fax: 757-591-2125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104001063
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberVA0101022154
License Number StateVA

VIII. Authorized Official

Name: MICHAEL S COOK
Title or Position: OWNER
Credential: DC
Phone: 757-591-7291