Provider Demographics
NPI:1700079092
Name:MASTERPEACE CHIROPRACTIC CENTER, P.C.
Entity Type:Organization
Organization Name:MASTERPEACE CHIROPRACTIC CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:MANNINO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:703-490-4242
Mailing Address - Street 1:3302 OLD BRIDGE RD
Mailing Address - Street 2:SUITE GH
Mailing Address - City:LAKE RIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-5262
Mailing Address - Country:US
Mailing Address - Phone:703-490-4242
Mailing Address - Fax:703-491-6370
Practice Address - Street 1:3302 OLD BRIDGE RD
Practice Address - Street 2:SUITE GH
Practice Address - City:LAKE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-5262
Practice Address - Country:US
Practice Address - Phone:703-490-4242
Practice Address - Fax:703-491-6370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104000675111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT21935Medicare UPIN