Healthcare Provider Details

I. General information

NPI: 1083095491
Provider Name (Legal Business Name): KEYA HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 06/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 ROBERT FULTON DR STE 480
RESTON VA
20191-5481
US

IV. Provider business mailing address

1801 ROBERT FULTON DR STE 480
RESTON VA
20191-5481
US

V. Phone/Fax

Practice location:
  • Phone: 703-261-7000
  • Fax: 708-860-1040
Mailing address:
  • Phone: 703-261-7000
  • Fax: 708-860-1040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MS. SEBLE WONGEL DEJENE
Title or Position: PRESIDENT
Credential:
Phone: 703-261-7001