=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265903751
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOVA SPINE & REHAB CENTER INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2018
-----------------------------------------------------
Last Update Date | 11/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 803 W BROAD ST STE 240A
-----------------------------------------------------
City | FALLS CHURCH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22046-3108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-606-2013
-----------------------------------------------------
Fax | 703-237-2839
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5811 HAMPTON FOREST WAY
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22030-7254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-739-5850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHAEL ARMELLINO
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 410-739-5850
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------