Healthcare Provider Details

I. General information

NPI: 1801499165
Provider Name (Legal Business Name): INDOMITABLE SPIRIT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2020
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12020 SUNRISE VALLEY DR STE 100
RESTON VA
20191-3429
US

IV. Provider business mailing address

3632 HOLBORN PL
FREDERICK MD
21704-7394
US

V. Phone/Fax

Practice location:
  • Phone: 703-376-7768
  • Fax:
Mailing address:
  • Phone: 425-877-0018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: JANELL KAPLAN
Title or Position: SOLE MEMBER
Credential:
Phone: 703-376-7768