Provider Demographics
NPI:1770743775
Name:LUCIANO, JAIME DIANA (DC)
Entity type:Individual
Prefix:
First Name:JAIME
Middle Name:DIANA
Last Name:LUCIANO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 SPILLWAY CT
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25405-6394
Mailing Address - Country:US
Mailing Address - Phone:703-919-8691
Mailing Address - Fax:
Practice Address - Street 1:102 ELDEN ST
Practice Address - Street 2:SUITE 13
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4868
Practice Address - Country:US
Practice Address - Phone:703-742-5470
Practice Address - Fax:703-742-0435
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-12
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556668111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor