Provider Demographics
NPI:1346297116
Name:PEPPERWOLF SPINAL CARE INSTITUTE LLC
Entity Type:Organization
Organization Name:PEPPERWOLF SPINAL CARE INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:A
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:703-204-2320
Mailing Address - Street 1:2136 GALLOWS ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:DUNN LORING
Mailing Address - State:VA
Mailing Address - Zip Code:22027-1036
Mailing Address - Country:US
Mailing Address - Phone:703-204-2320
Mailing Address - Fax:703-204-1618
Practice Address - Street 1:2136 GALLOWS ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:DUNN LORING
Practice Address - State:VA
Practice Address - Zip Code:22027-1036
Practice Address - Country:US
Practice Address - Phone:703-204-2320
Practice Address - Fax:703-204-1618
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEPPERWOLF SPINAL CARE INSTITUTE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-27
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1747111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA256800OtherBLUE CROSS BLUE SHIELD
VAU78196Medicare UPIN
VA000N02P06Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER
VAG00306Medicare ID - Type UnspecifiedGROUP #