Healthcare Provider Details

I. General information

NPI: 1831926757
Provider Name (Legal Business Name): METHUSELAH FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2024
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8021 FLINT ST
SPRINGFIELD VA
22153-2438
US

IV. Provider business mailing address

8021 FLINT ST
SPRINGFIELD VA
22153-2438
US

V. Phone/Fax

Practice location:
  • Phone: 818-321-8568
  • Fax:
Mailing address:
  • Phone: 818-321-8568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: EMMANUEL RAYES
Title or Position: ATTORNEY
Credential: ESQ.
Phone: 818-321-8568