MEDICARE: BALLSTON PAIN AND REHAB CENTER, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NR0400X	Rehabilitation Chiropractor	0104555796	VA

General Provider Information

NPI Number	:	1306142252
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALLSTON PAIN AND REHAB CENTER, PC

Provider Business Mailing Address
First Line	:	4238 WILSON BLVD
Second Line	:	THIRD FLOOR, SUITE 3018
City	:	ARLINGTON
State	:	VA
Zip	:	22203-1823
Country	:	US
Telephone Number	:	703-558-0001
Fax Number	:	703-558-3636

Provider Business Practice Location Address
First Line	:	4238 WILSON BLVD
Second Line	:	THIRD FLOOR, SUITE 3018
City	:	ARLINGTON
State	:	VA
Zip	:	22203-1823
Country	:	US
Telephone Number	:	703-558-0001
Fax Number	:	703-558-3636

Authorized Official
Title or Position	:	OWNER
Name	:	ERIK WARD
Credential	:	D.C.
Telephone Number	:	703-558-0007

Provider Enumeration Date	:	02/09/2011
Last Update Date	:	02/09/2011

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