Healthcare Provider Details

I. General information

NPI: 1366267304
Provider Name (Legal Business Name): LIFE TREE CARE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2024
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11240 WAPLES MILL RD STE 201
FAIRFAX VA
22030-6078
US

IV. Provider business mailing address

11240 WAPLES MILL RD STE 201
FAIRFAX VA
22030-6078
US

V. Phone/Fax

Practice location:
  • Phone: 434-212-0460
  • Fax: 703-570-7668
Mailing address:
  • Phone: 434-212-0460
  • Fax: 703-570-7668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number StateNULL
# 10
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateNULL
# 11
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number StateNULL
# 12
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateNULL
# 13
Primary TaxonomyN
Taxonomy Code3140N1450X
TaxonomyPediatric Skilled Nursing Facility
License Number
License Number StateNULL
# 14
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number StateNULL
# 15
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: KYONG HOON KO
Title or Position: PRESIDENT
Credential: PMP
Phone: 434-212-0460