Provider Demographics
NPI:1043387376
Name:POTOMAC FAMILY AND SPORTS CHIROPRACTIC CENTER INC
Entity Type:Organization
Organization Name:POTOMAC FAMILY AND SPORTS CHIROPRACTIC CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMINN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:703-406-8686
Mailing Address - Street 1:21351 GENTRY DR
Mailing Address - Street 2:SUITE 125
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20166-8510
Mailing Address - Country:US
Mailing Address - Phone:703-406-8686
Mailing Address - Fax:703-406-8688
Practice Address - Street 1:21351 GENTRY DR
Practice Address - Street 2:SUITE 125
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20166-8510
Practice Address - Country:US
Practice Address - Phone:703-406-8686
Practice Address - Fax:703-406-8688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001404111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA629493OtherACN
VA211692OtherANTHEM
VA4400165OtherUHC
VA4400165OtherUHC
VA629493OtherACN