Provider Demographics
NPI:1104461441
Name:PRIMUS PHYSICAL THERAPY FAIRFAX
Entity type:Organization
Organization Name:PRIMUS PHYSICAL THERAPY FAIRFAX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SERVICES DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KAYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBISON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:703-548-4400
Mailing Address - Street 1:6101 REDWOOD SQUARE CTR STE 202
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-4269
Mailing Address - Country:US
Mailing Address - Phone:703-543-6660
Mailing Address - Fax:
Practice Address - Street 1:3025 HAMAKER CT STE 103
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2221
Practice Address - Country:US
Practice Address - Phone:703-548-4400
Practice Address - Fax:703-995-0284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-11
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy