Provider Demographics
NPI:1356893879
Name:VIRGINIA NEUROSPINE PC
Entity type:Organization
Organization Name:VIRGINIA NEUROSPINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIALNTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLEGALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-200-9009
Mailing Address - Street 1:1019A VISTA PARK DR
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-4901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1019A VISTA PARK DR
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:VA
Practice Address - Zip Code:24551-4901
Practice Address - Country:US
Practice Address - Phone:434-200-9009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-01
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101250836207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty