Healthcare Provider Details

I. General information

NPI: 1306738661
Provider Name (Legal Business Name): AURUM PROVIDENCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2025
Last Update Date: 01/02/2026
Certification Date: 01/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4406 TULIP TREE CT
CHANTILLY VA
20151-2441
US

IV. Provider business mailing address

4371 STRAWFLOWER ST
FAIRFAX VA
22030-5781
US

V. Phone/Fax

Practice location:
  • Phone: 703-899-6774
  • Fax:
Mailing address:
  • Phone: 703-899-6774
  • 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
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. TAEKSOO LEE
Title or Position: CEO
Credential:
Phone: 703-899-6774