Provider Demographics
NPI:1871716563
Name:FAIRFAX PHYSICAL THERAPY, INCORPORATED
Entity type:Organization
Organization Name:FAIRFAX PHYSICAL THERAPY, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:703-934-9411
Mailing Address - Street 1:10525 WEST DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-4230
Mailing Address - Country:US
Mailing Address - Phone:703-934-9411
Mailing Address - Fax:703-934-9497
Practice Address - Street 1:10525 WEST DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-4230
Practice Address - Country:US
Practice Address - Phone:703-934-9411
Practice Address - Fax:703-934-9497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23050025662251X0800X
VA23052032532251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA726482Medicare ID - Type Unspecified