Healthcare Provider Details

I. General information

NPI: 1184173403
Provider Name (Legal Business Name): VIRGINIA INTEGRATIVE HEALTH & HYPERBARIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2016
Last Update Date: 09/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 PINE ST SE SUITE 320
VIENNA VA
22180-4861
US

IV. Provider business mailing address

410 PINE ST SE SUITE 320
VIENNA VA
22180-4861
US

V. Phone/Fax

Practice location:
  • Phone: 703-938-1421
  • Fax: 703-938-1424
Mailing address:
  • Phone: 703-938-1421
  • Fax: 703-938-1424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number0101231928
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number0101231928
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101231928
License Number StateVA

VIII. Authorized Official

Name: MS. YVOUNE PETRIE
Title or Position: DIRECTOR
Credential:
Phone: 703-938-1421