Healthcare Provider Details

I. General information

NPI: 1508544941
Provider Name (Legal Business Name): GOODWILL HOMES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2023
Last Update Date: 09/11/2025
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13126 MERCURY LN
FAIRFAX VA
22033-3711
US

IV. Provider business mailing address

13126 MERCURY LN
FAIRFAX VA
22033-3711
US

V. Phone/Fax

Practice location:
  • Phone: 202-258-3344
  • Fax:
Mailing address:
  • Phone: 202-258-3344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: ROGER LEYOU
Title or Position: CEO
Credential:
Phone: 202-258-3344