Provider Demographics
NPI:1275729501
Name:MULTI-DISCIPLINE ALT CARE CENTERS, LLC
Entity Type:Organization
Organization Name:MULTI-DISCIPLINE ALT CARE CENTERS, LLC
Other - Org Name:ROSELLE CENTER FOR HEALING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:ROSELLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:703-698-7117
Mailing Address - Street 1:8500 EXECUTIVE PARK AVENUE
Mailing Address - Street 2:#300
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4647
Mailing Address - Country:US
Mailing Address - Phone:703-698-7117
Mailing Address - Fax:703-698-5729
Practice Address - Street 1:8500 EXECUTIVE PARK AVENUE
Practice Address - Street 2:#300
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4647
Practice Address - Country:US
Practice Address - Phone:703-698-7117
Practice Address - Fax:703-698-5729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA475913Medicare PIN