Provider Demographics
NPI:1417620659
Name:CORE PAIN & WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:CORE PAIN & WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:TAEJOO
Authorized Official - Last Name:JEONG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:703-814-6650
Mailing Address - Street 1:10721 MAIN ST STE G7
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6913
Mailing Address - Country:US
Mailing Address - Phone:703-814-6650
Mailing Address - Fax:
Practice Address - Street 1:10721 MAIN ST STE G7
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6913
Practice Address - Country:US
Practice Address - Phone:703-814-6650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-25
Last Update Date:2021-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty