Provider Demographics
NPI:1841489531
Name:SPINE AND SPORT REHAB CENTER INC
Entity type:Organization
Organization Name:SPINE AND SPORT REHAB CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:703-998-0600
Mailing Address - Street 1:4656D KING ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-1215
Mailing Address - Country:US
Mailing Address - Phone:703-998-0600
Mailing Address - Fax:703-998-0333
Practice Address - Street 1:4656D KING ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-1215
Practice Address - Country:US
Practice Address - Phone:703-998-0600
Practice Address - Fax:703-998-0333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556081273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG01598Medicare PIN