Provider Demographics
NPI:1770196370
Name:PHYSIOCORE LLC
Entity Type:Organization
Organization Name:PHYSIOCORE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:703-399-5058
Mailing Address - Street 1:10268 LATNEY RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-3256
Mailing Address - Country:US
Mailing Address - Phone:703-399-5058
Mailing Address - Fax:
Practice Address - Street 1:10268 LATNEY RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22032-3256
Practice Address - Country:US
Practice Address - Phone:703-399-5058
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health