Healthcare Provider Details

I. General information

NPI: 1093175663
Provider Name (Legal Business Name): FIRSTCARE FLU & WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2016
Last Update Date: 02/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1751 PINNACLE DR SUITE 600
MC LEAN VA
22102-4903
US

IV. Provider business mailing address

1751 PINNACLE DR SUITE 600
MC LEAN VA
22102-4903
US

V. Phone/Fax

Practice location:
  • Phone: 800-750-2019
  • Fax: 909-295-3142
Mailing address:
  • Phone: 800-750-2019
  • Fax: 909-295-3142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number0102201555
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0102201555
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number0102201555
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number0102201555
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number0102201555
License Number StateVA
# 6
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0102201555
License Number StateVA
# 7
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number0102201555
License Number StateVA

VIII. Authorized Official

Name: MR. WILTON RICARDO SCOTT
Title or Position: CEO
Credential:
Phone: 909-784-2203