Provider Demographics
NPI:1154673366
Name:INNER CORE WELLNESS LLC
Entity Type:Organization
Organization Name:INNER CORE WELLNESS LLC
Other - Org Name:INNER CORE WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:LOURDES
Authorized Official - Last Name:SISON-WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:703-506-1010
Mailing Address - Street 1:2108 GALLOWS RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3980
Mailing Address - Country:US
Mailing Address - Phone:703-506-1010
Mailing Address - Fax:703-763-2333
Practice Address - Street 1:2108 GALLOWS RD
Practice Address - Street 2:SUITE A
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3980
Practice Address - Country:US
Practice Address - Phone:703-506-1010
Practice Address - Fax:703-763-2333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305004830225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty