Healthcare Provider Details

I. General information

NPI: 1962196014
Provider Name (Legal Business Name): IN-HOME SUPPORTIVE SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2023
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3526 NEXUS CT
WOODBRIDGE VA
22192-4437
US

IV. Provider business mailing address

3526 NEXUS CT
WOODBRIDGE VA
22192-4437
US

V. Phone/Fax

Practice location:
  • Phone: 510-677-8671
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State

VIII. Authorized Official

Name: LIDA NAB
Title or Position: OWNER
Credential:
Phone: 510-677-8671