=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730482159
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIYOSHI YAMAMOTO LAC., LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2010
-----------------------------------------------------
Last Update Date | 08/31/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1033 STERLING RD STE 105
-----------------------------------------------------
City | HERNDON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20170-3837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-855-3514
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5104 CASTLE HARBOR WAY
-----------------------------------------------------
City | CENTREVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20120-4140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-855-3514
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 19003726
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 0121000947
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------