Provider Demographics
NPI:1619389657
Name:MISSING LINK PHYSICAL THERAPY
Entity Type:Organization
Organization Name:MISSING LINK PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:HELETSI
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, OCS
Authorized Official - Phone:703-858-5070
Mailing Address - Street 1:44933 GEORGE WASHINGTON BLVD
Mailing Address - Street 2:SUITE 165
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-6300
Mailing Address - Country:US
Mailing Address - Phone:703-858-5070
Mailing Address - Fax:703-858-5904
Practice Address - Street 1:44933 GEORGE WASHINGTON BLVD
Practice Address - Street 2:SUITE 165
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-6300
Practice Address - Country:US
Practice Address - Phone:703-858-5070
Practice Address - Fax:703-858-5904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-26
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305204989261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1780898023OtherINDIVIDUAL NPI NUMBER