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General NPI Number Information
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NPI Number | 1013234657
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Entity Type | Organization
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Legal Business Name | IMMACULATE PHYSICAL THERAPY PC
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Dates
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Enumeration Date | 04/21/2010
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Last Update Date | 04/21/2010
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Provider Practice Location Address
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Address Line | 117 CASMAR ST SE
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City | VIENNA
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State | VA
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Zip | 22180-6610
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Country | US
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Telephone | 703-309-7028
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Fax | 800-928-5061
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Provider Business Mailing Address
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Address Line | 117 CASMAR ST SE
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City | VIENNA
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State | VA
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Zip | 22180-6610
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Country | US
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Telephone | 703-309-7028
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Fax | 800-928-5061
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Authorized Official
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Title or Position | DIRECTOR
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Name | MRS. DALIA M ELASHKER
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Credential | PHYSICAL THERAPIST
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Telephone | 703-309-7028
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 2305204191
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 2305205493
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License Number State | VA
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