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General NPI Number Information
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NPI Number | 1376807065
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Entity Type | Organization
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Legal Business Name | COLLEGE SPORTS REHAB
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Dates
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Enumeration Date | 06/27/2012
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Last Update Date | 06/27/2012
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Provider Practice Location Address
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Address Line | 1301 COLLEGE AVE GOOLRICK HALL ATHLETIC TRAINING ROOM (ROOM 102)
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City | FREDERICKSBURG
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State | VA
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Zip | 22401-5300
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Country | US
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Telephone | 703-314-9891
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Fax |
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Provider Business Mailing Address
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Address Line | 15597 HORSESHOE LN
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City | WOODBRIDGE
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State | VA
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Zip | 22191-4128
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Country | US
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Telephone | 703-314-9891
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Fax |
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Authorized Official
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Title or Position | CO-OWNER
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Name | MR. KEIRON ALLEN HOLMES
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Credential | PT, DPT, SCS
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Telephone | 703-314-9891
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 870876
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License Number State | DC
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Taxonomy #2
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 2305205379
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License Number State | VA
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