=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336508910
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 3D BODY IMAGING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2016
-----------------------------------------------------
Last Update Date | 02/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3023 HAMAKER CT LL50
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22031-2207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-849-8808
-----------------------------------------------------
Fax | 703-942-6062
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11002 BLENHEIM DR
-----------------------------------------------------
City | OAKTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22124-1801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-849-8808
-----------------------------------------------------
Fax | 703-942-6062
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LUKE STIKELEATHER
-----------------------------------------------------
Credential | CO
-----------------------------------------------------
Telephone | 703-849-2208
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------