Healthcare Provider Details

I. General information

NPI: 1710891791
Provider Name (Legal Business Name): MIDWEST ROLL HOUSE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5009 STEDWICK CT APT 101
VIRGINIA BEACH VA
23455-3815
US

IV. Provider business mailing address

5009 STEDWICK CT APT 101
VIRGINIA BEACH VA
23455-3815
US

V. Phone/Fax

Practice location:
  • Phone: 757-681-2377
  • Fax:
Mailing address:
  • Phone: 757-681-2377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number StateNULL

VIII. Authorized Official

Name: KINCHASSA BROWN
Title or Position: MANAGING MEMBER
Credential:
Phone: 757-681-2377