Provider Demographics
NPI:1376226456
Name:PERFECT STORM
Entity Type:Organization
Organization Name:PERFECT STORM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MONDERRAY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLASSINGAME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-388-9073
Mailing Address - Street 1:6800 FLEETWOOD RD STE 110
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3604
Mailing Address - Country:US
Mailing Address - Phone:703-388-9073
Mailing Address - Fax:
Practice Address - Street 1:6800 FLEETWOOD RD STE 110
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3604
Practice Address - Country:US
Practice Address - Phone:703-388-9073
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty