=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609376649
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIA VITAE CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2018
-----------------------------------------------------
Last Update Date | 02/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4511 JOHN TYLER HWY STE B
-----------------------------------------------------
City | WILLIAMSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23185-2415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-208-7108
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4511 JOHN TYLER HWY STE B
-----------------------------------------------------
City | WILLIAMSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23185-2415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-208-7108
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BRANDON BABIN
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 757-208-7108
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 0104557448
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------