Provider Demographics
NPI:1497181077
Name:VIRGINIA SPORTS CHIROPRACTIC OF FAIRFAX, PC
Entity Type:Organization
Organization Name:VIRGINIA SPORTS CHIROPRACTIC OF FAIRFAX, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:DANEEN
Authorized Official - Last Name:MORIARTY
Authorized Official - Suffix:
Authorized Official - Credentials:DC DACBSP
Authorized Official - Phone:703-675-7179
Mailing Address - Street 1:4211 FAIRFAX CORNER AVE E STE 200
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-8630
Mailing Address - Country:US
Mailing Address - Phone:703-222-6211
Mailing Address - Fax:703-738-7499
Practice Address - Street 1:4211 FAIRFAX CORNER AVE E STE 200
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-8630
Practice Address - Country:US
Practice Address - Phone:703-222-6211
Practice Address - Fax:703-738-7499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-16
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA104556132111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC08923Medicare PIN