Healthcare Provider Details

I. General information

NPI: 1013271360
Provider Name (Legal Business Name): MEDI-SSAGE CLINIC OF NORTHERN VIRGINIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2012
Last Update Date: 07/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 S 2ND ST
WARRENTON VA
20186-3338
US

IV. Provider business mailing address

20 S 2ND ST
WARRENTON VA
20186-3338
US

V. Phone/Fax

Practice location:
  • Phone: 540-347-3369
  • Fax:
Mailing address:
  • Phone: 540-347-3369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MIRIAM LEE WHITE
Title or Position: OWNER
Credential: LMT, MMP
Phone: 540-347-3369