Provider Demographics
NPI:1336510395
Name:RIVERSIDE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:RIVERSIDE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALEED
Authorized Official - Middle Name:MAHMOUD
Authorized Official - Last Name:ABUL-HAWA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:703-739-0500
Mailing Address - Street 1:205A THE STRAND
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-3367
Mailing Address - Country:US
Mailing Address - Phone:703-739-0500
Mailing Address - Fax:866-545-1147
Practice Address - Street 1:205A THE STRAND
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-3367
Practice Address - Country:US
Practice Address - Phone:703-739-0500
Practice Address - Fax:866-545-1147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001959111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA490329Medicare PIN
VAU75100Medicare UPIN