=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457236994
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SL HOLISTIC SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2025
-----------------------------------------------------
Last Update Date | 08/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4216 EVERGREEN LN STE 121
-----------------------------------------------------
City | ANNANDALE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22003-3256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-939-1722
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2371
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22031-0371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-989-6849
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | YEIMI MARCELA LAPHAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 703-989-6849
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------