Healthcare Provider Details

I. General information

NPI: 1174160048
Provider Name (Legal Business Name): DWELT GROUP HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2019
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15125 CARDIN PL
WOODBRIDGE VA
22193-5338
US

IV. Provider business mailing address

15125 CARDIN PL
WOODBRIDGE VA
22193-5338
US

V. Phone/Fax

Practice location:
  • Phone: 571-402-7989
  • Fax:
Mailing address:
  • Phone: 571-402-7989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CHRISTELLE ISAMBO
Title or Position: DIRECTOR
Credential:
Phone: 571-402-7989