Healthcare Provider Details

I. General information

NPI: 1043954431
Provider Name (Legal Business Name): KENNETH TRI LUONG DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2022
Last Update Date: 05/02/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14535 JOHN MARSHALL HWY STE 104
GAINESVILLE VA
20155-4024
US

IV. Provider business mailing address

14535 JOHN MARSHALL HWY
GAINESVILLE VA
20155-4023
US

V. Phone/Fax

Practice location:
  • Phone: 703-753-0974
  • Fax: 703-753-9709
Mailing address:
  • Phone: 703-753-0974
  • Fax: 703-753-9709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number0104-557821
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: