1275729501 NPI number — MULTI-DISCIPLINE ALT CARE CENTERS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275729501 NPI number — MULTI-DISCIPLINE ALT CARE CENTERS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MULTI-DISCIPLINE ALT CARE CENTERS, 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:
ROSELLE CENTER FOR HEALING
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:
1275729501
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8500 EXECUTIVE PARK AVENUE
Provider Second Line Business Mailing Address:
#300
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22031-4647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-698-7117
Provider Business Mailing Address Fax Number:
703-698-5729

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8500 EXECUTIVE PARK AVENUE
Provider Second Line Business Practice Location Address:
#300
Provider Business Practice Location Address City Name:
FAIRFAX
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22031-4647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-698-7117
Provider Business Practice Location Address Fax Number:
703-698-5729
Provider Enumeration Date:
09/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROSELLE
Authorized Official First Name:
RUSSELL
Authorized Official Middle Name:
THOMAS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
703-698-7117

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , 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)





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