Healthcare Provider Details

I. General information

NPI: 1124374061
Provider Name (Legal Business Name): LONE JACK HOLDINGS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2012
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10517 BRADDOCK RD STE C
FAIRFAX VA
22032-2275
US

IV. Provider business mailing address

10517 BRADDOCK RD STE C
FAIRFAX VA
22032-2275
US

V. Phone/Fax

Practice location:
  • Phone: 703-267-2380
  • Fax: 703-267-2384
Mailing address:
  • Phone: 703-267-2380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT WITHERS MASSIE IV
Title or Position: PRESIDENT
Credential:
Phone: 630-699-5900