Provider Demographics
NPI:1417722091
Name:CHEN, SI N/A
Entity Type:Individual
Prefix:
First Name:SI
Middle Name:N/A
Last Name:CHEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11663 CHARTER OAK CT APT 202
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-4534
Mailing Address - Country:US
Mailing Address - Phone:571-314-6251
Mailing Address - Fax:
Practice Address - Street 1:11703 BOWMAN GREEN DR
Practice Address - Street 2:SUITE 100
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190
Practice Address - Country:US
Practice Address - Phone:571-325-9393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-23
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019018570225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist