Provider Demographics
NPI:1770031916
Name:WYNN WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:WYNN WELLNESS CENTER LLC
Other - Org Name:EXECUTIVE PARK CHIROPRACTIC & ACUPUNCTURE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VU
Authorized Official - Middle Name:H
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:703-810-3311
Mailing Address - Street 1:8500 EXECUTIVE PARK AVE
Mailing Address - Street 2:SUITE 308
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2225
Mailing Address - Country:US
Mailing Address - Phone:703-810-3311
Mailing Address - Fax:
Practice Address - Street 1:8500 EXECUTIVE PARK AVE
Practice Address - Street 2:SUITE 308
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2225
Practice Address - Country:US
Practice Address - Phone:703-810-3311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-16
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556723111N00000X
VA0104557322111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA149951OtherMEDICARE PTAN