1578553970 NPI number — LEESBURG LIFE CARE, LLC

Table of content: (NPI 1578553970)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578553970 NPI number — LEESBURG LIFE CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEESBURG LIFE CARE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HERITAGE HALL - LEESBURG
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578553970
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/06/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3131 ELECTRIC RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24018-6427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-774-4263
Provider Business Mailing Address Fax Number:
540-774-0780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
122 MORVEN PARK RD NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20176
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-777-8700
Provider Business Practice Location Address Fax Number:
703-777-1532
Provider Enumeration Date:
10/26/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HAINES
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CCO & GENERAL COUNSEL
Authorized Official Telephone Number:
540-774-4263

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH2584 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200515604 . This is a "FEDERAL BLACK LUNG ID" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 180509 . This is a "ANTHEM BCBS PROVIDER ID" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 4952618 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".