Provider Demographics
NPI:1013416569
Name:NOVA BACK DOCTOR PPLC
Entity Type:Organization
Organization Name:NOVA BACK DOCTOR PPLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:CRANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:703-719-0900
Mailing Address - Street 1:6080 FRANCONIA RD STE B
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310-4427
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6080 FRANCONIA RD STE B
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-4427
Practice Address - Country:US
Practice Address - Phone:703-719-0900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA396111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1073551685OtherCHIROPRACTOR