Provider Demographics
NPI:1730482159
Name:YAMAMOTO, KIYOSHI (LAC, LMT)
Entity Type:Individual
Prefix:
First Name:KIYOSHI
Middle Name:
Last Name:YAMAMOTO
Suffix:
Gender:M
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5104 CASTLE HARBOR WAY
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-4140
Mailing Address - Country:US
Mailing Address - Phone:703-855-3514
Mailing Address - Fax:
Practice Address - Street 1:1033 STERLING RD STE 105
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-3837
Practice Address - Country:US
Practice Address - Phone:703-855-3514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-07
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA19003726225700000X
VA0121000947171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist