Provider Demographics
NPI:1235710336
Name:OPTIMIZED SPORTS & FAMILY WELLNESS
Entity Type:Organization
Organization Name:OPTIMIZED SPORTS & FAMILY WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-927-3119
Mailing Address - Street 1:709 W POPLAR RD
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20164-5028
Mailing Address - Country:US
Mailing Address - Phone:703-927-3119
Mailing Address - Fax:
Practice Address - Street 1:631 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PURCELLVILLE
Practice Address - State:VA
Practice Address - Zip Code:20132-3012
Practice Address - Country:US
Practice Address - Phone:703-927-3119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty