Healthcare Provider Details

I. General information

NPI: 1922494459
Provider Name (Legal Business Name): INTEGRATIVE HYPERBARIC & WOUND CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2015
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 PINE ST SE SUITE 330
VIENNA VA
22180-4861
US

IV. Provider business mailing address

410 PINE ST SE SUITE 330
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 Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CALISTA PETRIE
Title or Position: CASE MANAGER
Credential:
Phone: 703-938-1421