Provider Demographics
NPI:1013271360
Name:MEDI-SSAGE CLINIC OF NORTHERN VIRGINIA
Entity Type:Organization
Organization Name:MEDI-SSAGE CLINIC OF NORTHERN VIRGINIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:LMT, MMP
Authorized Official - Phone:540-347-3369
Mailing Address - Street 1:20 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20186-3338
Mailing Address - Country:US
Mailing Address - Phone:540-347-3369
Mailing Address - Fax:
Practice Address - Street 1:20 S 2ND ST
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-3338
Practice Address - Country:US
Practice Address - Phone:540-347-3369
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation