1598203457 NPI number — BEDKNOBS AND BROOMSTIX HOMECARE

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 1598203457 NPI number — BEDKNOBS AND BROOMSTIX HOMECARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEDKNOBS AND BROOMSTIX HOMECARE
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:
Provider Other Organization Name Type Code:
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:
1598203457
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5868 MAPLEDALE PLZ
Provider Second Line Business Mailing Address:
#106
Provider Business Mailing Address City Name:
WOODBRIDGE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22193-4535
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-583-3561
Provider Business Mailing Address Fax Number:
855-332-8585

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12836 GLEN FOREST CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANASSAS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20112-8872
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-583-3561
Provider Business Practice Location Address Fax Number:
855-332-8585
Provider Enumeration Date:
02/10/2017

Additional Information

Authorized Official

Authorized Official Last Name:
LASSITER
Authorized Official First Name:
SHAWN
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICER
Authorized Official Telephone Number:
703-583-3561

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2 . This is a "HOMECARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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