=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063749554
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOME LINK CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2009
-----------------------------------------------------
Last Update Date | 07/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2110 GALLOWS RD STE C1
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22182-3962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-349-2113
-----------------------------------------------------
Fax | 703-995-0621
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2110 GALLOWS RD STE C1
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22182-3962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-349-2113
-----------------------------------------------------
Fax | 703-995-0621
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. NIKITA FEDOROV
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 703-349-2113
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------