Provider Demographics
NPI:1639515331
Name:IDEAL BODY WELLNESS
Entity Type:Organization
Organization Name:IDEAL BODY WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MAHONEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-856-6803
Mailing Address - Street 1:10348 BRITTENFORD DR
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-1860
Mailing Address - Country:US
Mailing Address - Phone:703-856-6803
Mailing Address - Fax:
Practice Address - Street 1:8206 LEESBURG PIKE STE 302
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-2614
Practice Address - Country:US
Practice Address - Phone:703-856-6803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty