Provider Demographics
NPI:1952687931
Name:IVY CLINIC FOR ACUPUNCTURE AND ORIENTAL MEDICINE, PLLC
Entity Type:Organization
Organization Name:IVY CLINIC FOR ACUPUNCTURE AND ORIENTAL MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:WEI
Authorized Official - Middle Name:
Authorized Official - Last Name:HONG-REN
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:339-223-6723
Mailing Address - Street 1:7209 HANSFORD CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22151-3000
Mailing Address - Country:US
Mailing Address - Phone:339-223-6723
Mailing Address - Fax:
Practice Address - Street 1:100 N WASHINGTON ST
Practice Address - Street 2:SUITE 311
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-4523
Practice Address - Country:US
Practice Address - Phone:339-223-6723
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-22
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121-000617171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty