Healthcare Provider Details

I. General information

NPI: 1417373622
Provider Name (Legal Business Name): CLASSIC CAREGIVERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2014
Last Update Date: 09/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6506 ROCK CRYSTAL DR
CLIFTON VA
20124-2520
US

IV. Provider business mailing address

6506 ROCK CRYSTAL DR
CLIFTON VA
20124-2520
US

V. Phone/Fax

Practice location:
  • Phone: 877-201-4579
  • Fax: 703-520-2802
Mailing address:
  • Phone: 877-201-4579
  • Fax: 703-520-2802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberHCO151201
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. LISA KERSHES
Title or Position: OWNER
Credential:
Phone: 877-201-4579