Healthcare Provider Details

I. General information

NPI: 1962413765
Provider Name (Legal Business Name): SPECIALIZED ORTHOPAEDIC SERVICES,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 MAPLE AVE WEST BUILDING F
VIENNA VA
22180-4307
US

IV. Provider business mailing address

307 MAPLE AVE WEST BUILDING F
VIENNA VA
22180-4307
US

V. Phone/Fax

Practice location:
  • Phone: 703-281-1200
  • Fax: 703-281-1201
Mailing address:
  • Phone: 703-281-1200
  • Fax: 703-281-1201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number1114
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN (JAY) R KURELICH JR.
Title or Position: PRESIDENT
Credential:
Phone: 703-281-1200