Provider Demographics
NPI:1417032103
Name:HOLISTIC ACUPUNCTURE AND PHYSICAL THERAPY CENTER, LLC
Entity Type:Organization
Organization Name:HOLISTIC ACUPUNCTURE AND PHYSICAL THERAPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SOPHIE
Authorized Official - Middle Name:X
Authorized Official - Last Name:DENG
Authorized Official - Suffix:
Authorized Official - Credentials:PT, LAC
Authorized Official - Phone:301-987-0596
Mailing Address - Street 1:957 RUSSELL AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20879-6215
Mailing Address - Country:US
Mailing Address - Phone:301-987-0596
Mailing Address - Fax:301-987-0398
Practice Address - Street 1:957 RUSSELL AVE
Practice Address - Street 2:SUITE B
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-6215
Practice Address - Country:US
Practice Address - Phone:301-987-0596
Practice Address - Fax:301-987-0398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD410117100Medicaid
MDG01718Medicare ID - Type Unspecified