Healthcare Provider Details

I. General information

NPI: 1952848368
Provider Name (Legal Business Name): MA'RRU OASIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2017
Last Update Date: 01/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11610 SUMMERFIELD CT
FREDERICKSBURG VA
22407-6040
US

IV. Provider business mailing address

11610 SUMMERFIELD CT
FREDERICKSBURG VA
22407-6040
US

V. Phone/Fax

Practice location:
  • Phone: 540-903-8723
  • Fax:
Mailing address:
  • Phone: 540-903-8723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateNC

VIII. Authorized Official

Name: MS. JEWEL LUMAURE WIGGLESWORTH
Title or Position: OWNER
Credential: CNA
Phone: 540-903-8723