Provider Demographics
NPI:1093159717
Name:MAPLE CHIROPRACTIC & ACUPUNCTURE CLINIC, LLC
Entity Type:Organization
Organization Name:MAPLE CHIROPRACTIC & ACUPUNCTURE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEYVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAHVERDI
Authorized Official - Suffix:
Authorized Official - Credentials:DC, LAC
Authorized Official - Phone:703-657-0202
Mailing Address - Street 1:10721 MAIN ST
Mailing Address - Street 2:SUITE # 2500
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6914
Mailing Address - Country:US
Mailing Address - Phone:703-657-0202
Mailing Address - Fax:703-657-0234
Practice Address - Street 1:10721 MAIN ST
Practice Address - Street 2:SUITE # 2500
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6914
Practice Address - Country:US
Practice Address - Phone:703-657-0202
Practice Address - Fax:703-657-0234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556725111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty