1407223662 NPI number — DYNAMIC REHAB AND SPINE CHANTILLY

Table of content: DR. CHINH DUC PHAM M.D. (NPI 1154385540)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407223662 NPI number — DYNAMIC REHAB AND SPINE CHANTILLY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DYNAMIC REHAB AND SPINE CHANTILLY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407223662
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14290 SULLYFIELD CIR
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
CHANTILLY
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20151-4000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-378-0908
Provider Business Mailing Address Fax Number:
703-378-0208

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14290 SULLYFIELD CIR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
CHANTILLY
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20151-4000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-378-0908
Provider Business Practice Location Address Fax Number:
703-378-0208
Provider Enumeration Date:
08/24/2015

Additional Information

Authorized Official

Authorized Official Last Name:
ERLE
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
703-378-0908

Provider Taxonomy Codes

  • Taxonomy code: 111NS0005X , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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