Provider Demographics
NPI:1184114068
Name:FREDERICKSBURG DME
Entity type:Organization
Organization Name:FREDERICKSBURG DME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:RENO
Authorized Official - Suffix:
Authorized Official - Credentials:DC, CCIC, ICCSP
Authorized Official - Phone:540-785-0200
Mailing Address - Street 1:4500 PLANK RD STE 1022
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-0120
Mailing Address - Country:US
Mailing Address - Phone:540-785-0200
Mailing Address - Fax:540-785-0660
Practice Address - Street 1:4500 PLANK RD STE 1022
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-0120
Practice Address - Country:US
Practice Address - Phone:540-785-0200
Practice Address - Fax:540-785-0660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104555960111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty