Provider Demographics
NPI:1285612283
Name:FAIRFAX REHABILITATION, INCORPORATED
Entity type:Organization
Organization Name:FAIRFAX REHABILITATION, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:ROCHON
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:703-273-9191
Mailing Address - Street 1:10301 DEMOCRACY LN
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2545
Mailing Address - Country:US
Mailing Address - Phone:703-273-9191
Mailing Address - Fax:703-273-9213
Practice Address - Street 1:10301 DEMOCRACY LN
Practice Address - Street 2:SUITE 100
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2545
Practice Address - Country:US
Practice Address - Phone:703-273-9191
Practice Address - Fax:703-273-9213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305001398261QR0400X
VA2305002194261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4979184Medicaid
VA496580Medicare ID - Type Unspecified