Healthcare Provider Details

I. General information

NPI: 1386548287
Provider Name (Legal Business Name): MOON ACUPUNCTURE AND HERB CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14631 ROUTE 29 STE B115
CENTREVILLE VA
20121-5824
US

IV. Provider business mailing address

4393 POPLAR TREE CT
CHANTILLY VA
20151-2523
US

V. Phone/Fax

Practice location:
  • Phone: 301-458-0734
  • Fax:
Mailing address:
  • Phone: 301-458-0734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MIKYOUNG KIM
Title or Position: MEMBER-MANAGED
Credential: L.AC
Phone: 301-458-0734