Provider Demographics
NPI:1710576400
Name:OMNI WELLNESS & PERFORMANCE
Entity Type:Organization
Organization Name:OMNI WELLNESS & PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHACON
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:703-989-6014
Mailing Address - Street 1:5589 GUINEA RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-4052
Mailing Address - Country:US
Mailing Address - Phone:703-989-6014
Mailing Address - Fax:
Practice Address - Street 1:5589 GUINEA RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22032-4052
Practice Address - Country:US
Practice Address - Phone:703-989-6014
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-16
Last Update Date:2021-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy