Provider Demographics
NPI:1114429768
Name:MVP FITNESS AND MASSAGE
Entity Type:Organization
Organization Name:MVP FITNESS AND MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MALIK
Authorized Official - Middle Name:
Authorized Official - Last Name:VANTERPOOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-302-4081
Mailing Address - Street 1:11604 BRONCO CT
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-2985
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11604 BRONCO CT
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-2985
Practice Address - Country:US
Practice Address - Phone:202-302-4081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC045878800Medicaid