Provider Demographics
NPI:1053427740
Name:PENINSULA PAIN AND REHABILITATION CENTER, INC.
Entity type:Organization
Organization Name:PENINSULA PAIN AND REHABILITATION CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:757-591-7291
Mailing Address - Street 1:11015 WARWICK BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-3225
Mailing Address - Country:US
Mailing Address - Phone:757-591-7291
Mailing Address - Fax:757-591-2125
Practice Address - Street 1:11015 WARWICK BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-3225
Practice Address - Country:US
Practice Address - Phone:757-591-7291
Practice Address - Fax:757-591-2125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001063111N00000X
VAVA0101022154174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05764Medicare ID - Type Unspecified