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General NPI Number Information
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NPI Number | 1205350469
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Entity Type | Organization
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Legal Business Name | NOVA IDEAL SPINE
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Dates
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Enumeration Date | 07/31/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 19301 WINMEADE DR STE 214
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City | LANSDOWNE
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State | VA
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Zip | 20176-6503
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Country | US
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Telephone | 571-707-8639
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Fax | 571-707-8642
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Provider Business Mailing Address
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Address Line | 19301 WINMEADE DR STE 214
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City | LANSDOWNE
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State | VA
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Zip | 20176-6503
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Country | US
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Telephone | 571-707-8639
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Fax | 571-707-8642
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | JEANNE PHELPS
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Credential |
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Telephone | 571-707-8639
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 0104556594
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License Number State | VA
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