Provider Demographics
NPI:1407223662
Name:DYNAMIC REHAB AND SPINE CHANTILLY
Entity Type:Organization
Organization Name:DYNAMIC REHAB AND SPINE CHANTILLY
Other - Org Name:DYNAMIC REHAB & SPINE CHANTILLY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ERLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:703-378-0908
Mailing Address - Street 1:14290 SULLYFIELD CIR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-4000
Mailing Address - Country:US
Mailing Address - Phone:703-378-0908
Mailing Address - Fax:703-378-0208
Practice Address - Street 1:14290 SULLYFIELD CIR
Practice Address - Street 2:SUITE 100
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-4000
Practice Address - Country:US
Practice Address - Phone:703-378-0908
Practice Address - Fax:703-378-0208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-24
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAU86852Medicare UPIN