Healthcare Provider Details

I. General information

NPI: 1649785676
Provider Name (Legal Business Name): MVP FITNESS AND MASSAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2017
Last Update Date: 03/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11604 BRONCO CT
UPPER MARLBORO MD
20772-2985
US

IV. Provider business mailing address

11604 BRONCO CT
UPPER MARLBORO MD
20772-2985
US

V. Phone/Fax

Practice location:
  • Phone: 202-302-4081
  • Fax:
Mailing address:
  • Phone: 202-302-4081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: MALIK VANTERPOOL
Title or Position: CEO
Credential:
Phone: 202-302-4081