Healthcare Provider Details

I. General information

NPI: 1598434524
Provider Name (Legal Business Name): MIGUEL OLIVERAS JR. DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2021
Last Update Date: 10/11/2021
Certification Date: 10/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13854 SMOKETOWN RD
WOODBRIDGE VA
22192-4210
US

IV. Provider business mailing address

4118 GRANBY RD
WOODBRIDGE VA
22193-2510
US

V. Phone/Fax

Practice location:
  • Phone: 703-670-9935
  • Fax: 703-670-9939
Mailing address:
  • Phone: 646-753-0798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104-557761
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: