Provider Demographics
NPI:1730689068
Name:JRGCC
Entity type:Organization
Organization Name:JRGCC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:GO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:607-329-8135
Mailing Address - Street 1:10507 BRADDOCK RD STE A
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-2240
Mailing Address - Country:US
Mailing Address - Phone:607-329-8135
Mailing Address - Fax:
Practice Address - Street 1:10507 BRADDOCK RD STE A
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22032-2240
Practice Address - Country:US
Practice Address - Phone:607-329-8135
Practice Address - Fax:607-329-8135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-13
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556606111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty