Healthcare Provider Details

I. General information

NPI: 1356783070
Provider Name (Legal Business Name): MONTCLAIR HOME HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2013
Last Update Date: 09/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4054 RAFT COVE CT
WOODBRIDGE VA
22193-5870
US

IV. Provider business mailing address

4054 RAFT COVE CT
WOODBRIDGE VA
22193-5870
US

V. Phone/Fax

Practice location:
  • Phone: 571-229-0268
  • Fax:
Mailing address:
  • Phone: 571-229-0268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberHCO-17979
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License NumberHCO-17979
License Number StateVA

VIII. Authorized Official

Name: MRS. ZAHRA M. MOHAMED
Title or Position: INTAKE COORDINATOR
Credential:
Phone: 571-229-0268