Healthcare Provider Details

I. General information

NPI: 1578496634
Provider Name (Legal Business Name): CNI HOMECARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42882 TRURO PARISH DR STE 206
BROADLANDS VA
20148-4458
US

IV. Provider business mailing address

42882 TRURO PARISH DR STE 206
BROADLANDS VA
20148-4458
US

V. Phone/Fax

Practice location:
  • Phone: 571-356-6627
  • Fax:
Mailing address:
  • Phone: 571-356-6627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: KENEDI ATIE AMBAN
Title or Position: CEO
Credential: CEO
Phone: 301-305-9600