Healthcare Provider Details

I. General information

NPI: 1093165672
Provider Name (Legal Business Name): BRIGHTVIEW FAIRFAX, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 GALLOWS ROAD
ANNANDALE VA
22003
US

IV. Provider business mailing address

3450 GALLOWS ROAD
ANNANDALE VA
22003
US

V. Phone/Fax

Practice location:
  • Phone: 703-462-9998
  • Fax: 703-992-7915
Mailing address:
  • Phone: 703-462-9998
  • Fax: 703-992-7915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State

VIII. Authorized Official

Name: DAVID GREYDANUS
Title or Position: AUTHORIZED SIGNATORY
Credential:
Phone: 410-962-0595