Provider Demographics
NPI:1669656971
Name:PAINREHAB
Entity Type:Organization
Organization Name:PAINREHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:QUIACHON
Authorized Official - Last Name:BAUTISTA-QUINT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-823-0063
Mailing Address - Street 1:2823 DUKE ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-4512
Mailing Address - Country:US
Mailing Address - Phone:703-823-0063
Mailing Address - Fax:702-823-0644
Practice Address - Street 1:2823 DUKE ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-4512
Practice Address - Country:US
Practice Address - Phone:703-823-0063
Practice Address - Fax:702-823-0644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01-1232198261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAH39514Medicare UPIN