Healthcare Provider Details

I. General information

NPI: 1629567656
Provider Name (Legal Business Name): LAURA BREEDEN L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2018
Last Update Date: 05/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3846 LYNDHURST DR APT 301
FAIRFAX, VA VA
22031
US

IV. Provider business mailing address

3846 LYNDHURST DR APT 301
FAIRFAX, VA VA
22031
US

V. Phone/Fax

Practice location:
  • Phone: 703-655-5442
  • Fax:
Mailing address:
  • Phone: 703-655-5442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number0121000829
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: