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General NPI Number Information
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NPI Number | 1164002895
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Entity Type | Organization
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Legal Business Name | ATHLETIC EDGE SPORTS MASSAGE, LLC
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Dates
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Enumeration Date | 04/08/2021
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Last Update Date | 04/08/2021
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Provider Practice Location Address
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Address Line | 226 MAPLE AVE W STE 303
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City | VIENNA
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State | VA
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Zip | 22180-5607
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Country | US
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Telephone | 571-259-4154
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Fax |
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Provider Business Mailing Address
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Address Line | 226 MAPLE AVE W STE 303
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City | VIENNA
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State | VA
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Zip | 22180-5607
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Country | US
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Telephone | 703-938-0315
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. MICHELLE A SWEENEY
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Credential | LMT
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Telephone | 571-259-4154
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number |
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License Number State |
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