Provider Demographics
NPI:1164619706
Name:SPORT & SPINE REHAB OF STERLING
Entity Type:Organization
Organization Name:SPORT & SPINE REHAB OF STERLING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANGER
Authorized Official - Prefix:
Authorized Official - First Name:TAWANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HACKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-766-0300
Mailing Address - Street 1:11418 LIVINGSTON RD
Mailing Address - Street 2:
Mailing Address - City:FT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-5145
Mailing Address - Country:US
Mailing Address - Phone:240-766-0300
Mailing Address - Fax:240-766-0304
Practice Address - Street 1:46440 BENEDICT DR
Practice Address - Street 2:STE 106
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-6602
Practice Address - Country:US
Practice Address - Phone:240-766-0300
Practice Address - Fax:240-766-0304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556518111N00000X, 111NR0200X
VA0104556529111N00000X, 111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NR0200XChiropractic ProvidersChiropractorRadiologyGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty