Provider Demographics
NPI:1538504246
Name:SHORT, JUSTIN JOSEPH (LAC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:JOSEPH
Last Name:SHORT
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:JUSTIN
Other - Middle Name:JOSEPH
Other - Last Name:GONSETH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7310 HERITAGE VILLAGE PLZ
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-3303
Mailing Address - Country:US
Mailing Address - Phone:571-477-5290
Mailing Address - Fax:
Practice Address - Street 1:7310 HERITAGE VILLAGE PLZ
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3303
Practice Address - Country:US
Practice Address - Phone:571-477-5290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-08
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000652171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist