1811334881 NPI number — BREAKTHROUGH CHIROPRACTIC CARE, LLC

Table of content: DAVID CORONA MELO DC (NPI 1639822265)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811334881 NPI number — BREAKTHROUGH CHIROPRACTIC CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BREAKTHROUGH CHIROPRACTIC CARE, LLC
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:
1811334881
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10640 MAIN ST STE 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22030-3930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-352-4357
Provider Business Mailing Address Fax Number:
703-649-6411

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10640 MAIN ST STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRFAX
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22030-3930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-352-4357
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/30/2013

Additional Information

Authorized Official

Authorized Official Last Name:
GLASMAN
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
NATHAN
Authorized Official Title or Position:
DOCTOR OF CHIROPRACTIC
Authorized Official Telephone Number:
703-477-9661

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  0104557055 , 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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