Provider Demographics
NPI:1194807958
Name:CENTREVILLE FAMILY CHIROPRACTIC
Entity type:Organization
Organization Name:CENTREVILLE FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOOSUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:703-378-1678
Mailing Address - Street 1:5900 CENTREVILLE RD STE 205
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-2425
Mailing Address - Country:US
Mailing Address - Phone:703-378-1678
Mailing Address - Fax:703-378-7147
Practice Address - Street 1:5900 CENTREVILLE RD STE 205
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2425
Practice Address - Country:US
Practice Address - Phone:703-378-1678
Practice Address - Fax:703-378-7147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG01848Medicare ID - Type Unspecified