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General NPI Number Information
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NPI Number | 1881114619
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Entity Type | Organization
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Legal Business Name | A VIVID AGE LLC
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Dates
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Enumeration Date | 06/22/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 2716 29TH ST SE APT B196
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City | WASHINGTON
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State | DC
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Zip | 20020-3170
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Country | US
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Telephone | 202-425-4137
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Fax |
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Provider Business Mailing Address
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Address Line | 2716 29TH ST SE APT B196
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City | WASHINGTON
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State | DC
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Zip | 20020-3170
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Country | US
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Telephone | 202-425-4137
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | VIVIANA SCOTT
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Credential |
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Telephone | 202-425-4137
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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