Provider Demographics
NPI:1417629387
Name:FAIRFAX CHIROPRACTIC AND WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:FAIRFAX CHIROPRACTIC AND WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF ENTITY
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:N
Authorized Official - Last Name:GLASMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:703-291-6677
Mailing Address - Street 1:10640 MAIN ST STE 103
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-3930
Mailing Address - Country:US
Mailing Address - Phone:703-291-6677
Mailing Address - Fax:703-352-8935
Practice Address - Street 1:10640 MAIN ST STE 103
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-3930
Practice Address - Country:US
Practice Address - Phone:703-291-6677
Practice Address - Fax:703-352-8935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-29
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty