Healthcare Provider Details

I. General information

NPI: 1548698665
Provider Name (Legal Business Name): INNATE FUSION, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 01/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 MAPLE AVE W SUITE L3
VIENNA VA
22180-5620
US

IV. Provider business mailing address

380 MAPLE AVE W SUITE L3
VIENNA VA
22180-5620
US

V. Phone/Fax

Practice location:
  • Phone: 703-242-0030
  • Fax:
Mailing address:
  • Phone: 703-242-0030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104557018
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License Number0104557018
License Number StateVA

VIII. Authorized Official

Name: DR. DOUGLAS PAUL KNAPP
Title or Position: DIRECTOR
Credential: D.C.
Phone: 703-242-0030