=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972463917
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL PAUL FONSECA DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2025
-----------------------------------------------------
Last Update Date | 11/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24600 MILLSTREAM DR STE 360
-----------------------------------------------------
City | ALDIE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20105-5686
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-487-7786
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24600 MILLSTREAM DR STE 360
-----------------------------------------------------
City | ALDIE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20105-5686
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-487-7786
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 0104558138
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------