Healthcare Provider Details

I. General information

NPI: 1639515331
Provider Name (Legal Business Name): IDEAL BODY WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2013
Last Update Date: 05/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8206 LEESBURG PIKE STE 302
VIENNA VA
22182-2614
US

IV. Provider business mailing address

10348 BRITTENFORD DR
VIENNA VA
22182-1860
US

V. Phone/Fax

Practice location:
  • Phone: 703-856-6803
  • Fax:
Mailing address:
  • Phone: 703-856-6803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL A MAHONEY
Title or Position: CEO
Credential:
Phone: 703-856-6803