Provider Demographics
NPI:1932499407
Name:SPORTS EDGE ACUPUNCTURE, LLC
Entity Type:Organization
Organization Name:SPORTS EDGE ACUPUNCTURE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HON
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, DAOM
Authorized Official - Phone:571-306-0533
Mailing Address - Street 1:1033 STERLING RD STE 105
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-3837
Mailing Address - Country:US
Mailing Address - Phone:571-306-0533
Mailing Address - Fax:703-537-0229
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:571-306-0533
Practice Address - Fax:703-537-0229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-18
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000348171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty