Healthcare Provider Details

I. General information

NPI: 1710291679
Provider Name (Legal Business Name): CCSP NOVA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2010
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46531 HARRY BYRD HWY
STERLING VA
20164-3555
US

IV. Provider business mailing address

5372 FALLOWATER LN SUITE 200
ROANOKE VA
24018-0907
US

V. Phone/Fax

Practice location:
  • Phone: 703-834-5800
  • Fax: 703-834-5905
Mailing address:
  • Phone: 540-725-8910
  • Fax: 540-725-8914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH2776
License Number StateVA

VIII. Authorized Official

Name: JOSEPH ANTHONY ALESANTRINO
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 540-725-8910