Healthcare Provider Details

I. General information

NPI: 1376226456
Provider Name (Legal Business Name): PERFECT STORM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2023
Last Update Date: 08/07/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6800 FLEETWOOD RD STE 110
MC LEAN VA
22101-3604
US

IV. Provider business mailing address

6800 FLEETWOOD RD STE 110
MC LEAN VA
22101-3604
US

V. Phone/Fax

Practice location:
  • Phone: 703-388-9073
  • Fax:
Mailing address:
  • Phone: 703-388-9073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name: MONDERRAY BLASSINGAME
Title or Position: COO
Credential:
Phone: 703-388-9073