=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174104772
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELECTROLYSIS PARTNERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2021
-----------------------------------------------------
Last Update Date | 04/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 421 CHURCH ST NE
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22180-4759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-255-7237
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6641 WAKEFIELD DR APT 403
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22307-6864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-220-6114
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MAUREEN SCHANTZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 703-255-7237
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------