Provider Demographics
NPI:1871850164
Name:CORE WELLNESS & PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:CORE WELLNESS & PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, FOUNDER, LEAD PT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:POLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:571-309-3048
Mailing Address - Street 1:2212 MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22301-1356
Mailing Address - Country:US
Mailing Address - Phone:571-403-2673
Mailing Address - Fax:571-366-2052
Practice Address - Street 1:2212 MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22301-1356
Practice Address - Country:US
Practice Address - Phone:571-403-2673
Practice Address - Fax:571-366-2052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-12
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305205043261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy