Healthcare Provider Details

I. General information

NPI: 1801316906
Provider Name (Legal Business Name): VLADIMIR LISS L.AC., M.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 12/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9709 SHADOW OAK DR
GAITHERSBURG MD
20886-1123
US

IV. Provider business mailing address

9709 SHADOW OAK DR
GAITHERSBURG MD
20886-1123
US

V. Phone/Fax

Practice location:
  • Phone: 347-701-3437
  • Fax:
Mailing address:
  • Phone: 347-701-3437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberU02408
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: