Healthcare Provider Details

I. General information

NPI: 1427709526
Provider Name (Legal Business Name): REBOOT FUNCTIONAL HEALTH CARE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2528 LAS BRISAS DR
VIRGINIA BEACH VA
23456-4264
US

IV. Provider business mailing address

2528 LAS BRISAS DR
VIRGINIA BEACH VA
23456-4264
US

V. Phone/Fax

Practice location:
  • Phone: 757-301-6985
  • Fax:
Mailing address:
  • Phone: 757-301-6985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. LAURIE DIERSTEIN
Title or Position: OWNER/AUTHORIZED OFFICIAL
Credential:
Phone: 757-301-6985