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General NPI Number Information
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NPI Number | 1710576400
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Entity Type | Organization
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Legal Business Name | OMNI WELLNESS & PERFORMANCE
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Dates
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Enumeration Date | 01/16/2021
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Last Update Date | 01/16/2021
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Provider Practice Location Address
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Address Line | 5589 GUINEA RD
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City | FAIRFAX
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State | VA
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Zip | 22032-4052
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Country | US
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Telephone | 703-989-6014
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Fax |
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Provider Business Mailing Address
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Address Line | 5589 GUINEA RD
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City | FAIRFAX
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State | VA
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Zip | 22032-4052
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Country | US
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Telephone | 703-989-6014
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. JOSE CHACON
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Credential | PTA
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Telephone | 703-989-6014
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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 |
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License Number State |
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