=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114150919
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOVA REHAB CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2009
-----------------------------------------------------
Last Update Date | 07/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4304 EVERGREEN LN STE 102
-----------------------------------------------------
City | ANNANDALE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22003-3216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-256-7979
-----------------------------------------------------
Fax | 703-256-7770
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4304 EVERGREEN LN #102
-----------------------------------------------------
City | ANNANDALE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-256-7979
-----------------------------------------------------
Fax | 703-256-7770
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KYUNG H KIM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 703-342-2612
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------