Provider Demographics
NPI:1023181302
Name:PROFESSIONAL CHIROPRACTIC & REHABILITION CENTER P.C.
Entity Type:Organization
Organization Name:PROFESSIONAL CHIROPRACTIC & REHABILITION CENTER P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SPEROS
Authorized Official - Middle Name:
Authorized Official - Last Name:TRYPHONAS
Authorized Official - Suffix:
Authorized Official - Credentials:BSC, DC
Authorized Official - Phone:757-424-2626
Mailing Address - Street 1:5386 KEMPSRIVER DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-5349
Mailing Address - Country:US
Mailing Address - Phone:757-424-2626
Mailing Address - Fax:757-366-0129
Practice Address - Street 1:5386 KEMPSRIVER DR
Practice Address - Street 2:SUITE 102
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-5349
Practice Address - Country:US
Practice Address - Phone:757-424-2626
Practice Address - Fax:757-366-0129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556069111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09759Medicare ID - Type UnspecifiedGROUP ID