Healthcare Provider Details

I. General information

NPI: 1164821484
Provider Name (Legal Business Name): MINERVA HOME HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2014
Last Update Date: 03/06/2024
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 VINCENT PL STE B
MC LEAN VA
22101-3614
US

IV. Provider business mailing address

1310 VINCENT PL STE B
MC LEAN VA
22101-3614
US

V. Phone/Fax

Practice location:
  • Phone: 240-603-5025
  • Fax: 855-639-0043
Mailing address:
  • Phone: 240-603-5025
  • Fax: 855-639-0043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number151193
License Number StateVA

VIII. Authorized Official

Name: MISS SHADE GREEN
Title or Position: DON
Credential: BSN
Phone: 240-603-5025