Healthcare Provider Details

I. General information

NPI: 1295654622
Provider Name (Legal Business Name): AXIONCREST HEALTH SYSTEMS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5568 GENERAL WASHINGTON DR STE A214
ALEXANDRIA VA
22312-2465
US

IV. Provider business mailing address

5568 GENERAL WASHINGTON DR STE A214
ALEXANDRIA VA
22312-2465
US

V. Phone/Fax

Practice location:
  • Phone: 571-778-1726
  • Fax:
Mailing address:
  • Phone: 571-450-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: LONGCHI GIDE KANOUO
Title or Position: MANAGER
Credential:
Phone: 571-450-2500