Healthcare Provider Details

I. General information

NPI: 1144041328
Provider Name (Legal Business Name): SOLACE GROVE ASSISTED LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38685 GOOSE CREEK LN
LEESBURG VA
20175-6642
US

IV. Provider business mailing address

1880 HOWARD AVE STE 301A
VIENNA VA
22182-2611
US

V. Phone/Fax

Practice location:
  • Phone: 703-462-9141
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State

VIII. Authorized Official

Name: IBRAHIM JUMA
Title or Position: OWNER
Credential:
Phone: 814-423-0387