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General NPI Number Information
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NPI Number | 1588056139
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Entity Type | Organization
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Legal Business Name | LIFELONG GOOD HEALTH LLC
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Dates
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Enumeration Date | 02/19/2015
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Last Update Date | 02/19/2015
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Provider Practice Location Address
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Address Line | 5721 RHODE ISALND DRIVE
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City | WOODBRIDGE
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State | VA
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Zip | 22193
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Country | US
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Telephone | 703-389-6612
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Fax |
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Provider Business Mailing Address
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Address Line | 14904 JEFFERSON DAVIS HWY
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City | WOODBRIDGE
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State | VA
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Zip | 22191-3908
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Country | US
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Telephone | 703-389-6612
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Fax |
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Authorized Official
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Title or Position | REGISTERED DIETITIAN NUTRITIONIST
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Name | MRS. LUCIA ISAC MITCHELL
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Credential | RDN
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Telephone | 703-389-6612
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | D1100000386
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License Number State | DC
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