Basic Information
| Provider Information | |||||||||
| NPI: | 1477587640 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHN J. BUCHBACH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | EAST COAST REHAB, LLC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4944C EISENHOWER AVE | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223044809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033705790 | ||||||||
| FaxNumber: | 7033705793 | ||||||||
| Practice Location | |||||||||
| Address1: | 4944C EISENHOWER AVE | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223044809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033705790 | ||||||||
| FaxNumber: | 7033705793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 06/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | BUCHBACH | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | JACOB | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7033705790 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BC3200X | 0622638 | VA | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment |
ID Information
| ID | Type | State | Issuer | Description | 009120335 | 05 | VA | MEDICAID |