Provider Demographics
NPI:1275918435
Name:FOUNDATION FITNESS OF ANNANDALE
Entity Type:Organization
Organization Name:FOUNDATION FITNESS OF ANNANDALE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:BRESLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CPT
Authorized Official - Phone:703-586-5833
Mailing Address - Street 1:7232 COLUMBIA PIKE
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-3145
Mailing Address - Country:US
Mailing Address - Phone:703-586-5833
Mailing Address - Fax:
Practice Address - Street 1:7232 COLUMBIA PIKE
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-3145
Practice Address - Country:US
Practice Address - Phone:703-586-5833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOUNDATION FITNESS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA255A2300X2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty