Provider Demographics
NPI:1376807065
Name:COLLEGE SPORTS REHAB
Entity Type:Organization
Organization Name:COLLEGE SPORTS REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEIRON
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, SCS
Authorized Official - Phone:703-314-9891
Mailing Address - Street 1:15597 HORSESHOE LN
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-4128
Mailing Address - Country:US
Mailing Address - Phone:703-314-9891
Mailing Address - Fax:
Practice Address - Street 1:1301 COLLEGE AVE
Practice Address - Street 2:GOOLRICK HALL ATHLETIC TRAINING ROOM (ROOM 102)
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-5300
Practice Address - Country:US
Practice Address - Phone:703-314-9891
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305205379261QP2000X
DC870876261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy