Provider Demographics
NPI:1477009108
Name:FAMILY AND SPORT CHIROPRACTIC
Entity Type:Organization
Organization Name:FAMILY AND SPORT CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPACTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WETZEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-560-4730
Mailing Address - Street 1:2727 MERRILEE DRIVE,
Mailing Address - Street 2:UNIT 421
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-8142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 N WASHINGTON ST
Practice Address - Street 2:SUITE #103
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-4426
Practice Address - Country:US
Practice Address - Phone:703-560-4730
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104557359111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty