Healthcare Provider Details

I. General information

NPI: 1881108835
Provider Name (Legal Business Name): SIRIWAT VIRIYAPANICH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2017
Last Update Date: 11/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3543 W BRADDOCK RD
ALEXANDRIA VA
22302-1900
US

IV. Provider business mailing address

7857 PAINTED DAISY DR
SPRINGFIELD VA
22152-3851
US

V. Phone/Fax

Practice location:
  • Phone: 703-578-1900
  • Fax:
Mailing address:
  • Phone: 703-463-7690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0019015428
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: