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General NPI Number Information
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NPI Number | 1376226456
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Entity Type | Organization
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Legal Business Name | PERFECT STORM
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Dates
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Enumeration Date | 08/07/2023
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Last Update Date | 08/07/2023
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Provider Practice Location Address
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Address Line | 6800 FLEETWOOD RD STE 110
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City | MC LEAN
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State | VA
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Zip | 22101-3604
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Country | US
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Telephone | 703-388-9073
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Fax |
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Provider Business Mailing Address
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Address Line | 6800 FLEETWOOD RD STE 110
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City | MC LEAN
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State | VA
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Zip | 22101-3604
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Country | US
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Telephone | 703-388-9073
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Fax |
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Authorized Official
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Title or Position | COO
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Name | MONDERRAY BLASSINGAME
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Credential |
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Telephone | 703-388-9073
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133NN1002X
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Taxonomy Name | Nutrition Education Nutritionist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 171400000X
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Taxonomy Name | Health & Wellness Coach
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 133N00000X
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Taxonomy Name | Nutritionist
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License Number |
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License Number State |
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