Healthcare Provider Details

I. General information

NPI: 1740662733
Provider Name (Legal Business Name): AMIN ROKNI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11700 BOWMAN GREEN DR
RESTON VA
20190-3501
US

IV. Provider business mailing address

9706 DAYS FARM DR
VIENNA VA
22182-7302
US

V. Phone/Fax

Practice location:
  • Phone: 571-375-2630
  • Fax:
Mailing address:
  • Phone: 760-898-4826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104-557265
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number33243
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number0104-557265
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: