Provider Demographics
NPI:1518409804
Name:OMNISPINE CHIROPRACTIC & REHAB CLINIC PC
Entity Type:Organization
Organization Name:OMNISPINE CHIROPRACTIC & REHAB CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHANG HA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:703-865-5899
Mailing Address - Street 1:3930 WALNUT ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-4738
Mailing Address - Country:US
Mailing Address - Phone:703-865-5899
Mailing Address - Fax:703-865-6199
Practice Address - Street 1:3930 WALNUT ST
Practice Address - Street 2:SUITE 220
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-4738
Practice Address - Country:US
Practice Address - Phone:703-865-5899
Practice Address - Fax:703-865-6199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-17
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104557024111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA225178Medicare PIN