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General NPI Number Information
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NPI Number | 1518409804
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Entity Type | Organization
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Legal Business Name | OMNISPINE CHIROPRACTIC & REHAB CLINIC PC
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Dates
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Enumeration Date | 11/17/2016
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Last Update Date | 11/17/2016
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Provider Practice Location Address
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Address Line | 3930 WALNUT ST SUITE 220
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City | FAIRFAX
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State | VA
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Zip | 22030-4738
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Country | US
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Telephone | 703-865-5899
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Fax | 703-865-6199
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Provider Business Mailing Address
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Address Line | 3930 WALNUT ST SUITE 220
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City | FAIRFAX
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State | VA
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Zip | 22030-4738
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Country | US
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Telephone | 703-865-5899
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Fax | 703-865-6199
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CHANG HA LEE
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Credential | D.C.
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Telephone | 703-865-5899
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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 | 0104557024
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License Number State | VA
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