=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336567627
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEUROSPINE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2014
-----------------------------------------------------
Last Update Date | 04/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8230 BOONE BLVD SUITE 360
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22182-2621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-889-8959
-----------------------------------------------------
Fax | 703-370-0706
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8230 BOONE BLVD SUITE 360
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22182-2621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-889-8959
-----------------------------------------------------
Fax | 703-370-0706
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | MRS. JANICE C CARSWELL STEWART
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-364-9010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 0101254853
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------