Healthcare Provider Details

I. General information

NPI: 1164348124
Provider Name (Legal Business Name): BLACKROUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11500 COMMERCE PARK DR APT 324
RESTON VA
20191-1173
US

IV. Provider business mailing address

11500 COMMERCE PARK DR APT 324
RESTON VA
20191-1173
US

V. Phone/Fax

Practice location:
  • Phone: 442-442-0544
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: REHMAN KHAN
Title or Position: MANAGER
Credential:
Phone: 442-442-0544