Healthcare Provider Details

I. General information

NPI: 1639642762
Provider Name (Legal Business Name): SENIORWELL OF VIRGINIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2019
Last Update Date: 01/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 BEAUFONT SPRINGS DR STE 300
NORTH CHESTERFIELD VA
23225-5519
US

IV. Provider business mailing address

2100 E LAKE COOK RD STE 1000
BUFFALO GROVE IL
60089-1999
US

V. Phone/Fax

Practice location:
  • Phone: 844-882-3127
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State

VIII. Authorized Official

Name: JOHN MORONEY
Title or Position: CEO
Credential:
Phone: 844-882-3127