=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184268955
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEL PROFESSIONAL HEALTHCARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2019
-----------------------------------------------------
Last Update Date | 11/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17472 TANGARIRO SQ
-----------------------------------------------------
City | DUMFRIES
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22025-1958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-402-2047
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17472 TANGARIRO SQ
-----------------------------------------------------
City | DUMFRIES
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22025-1958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-402-2047
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | VICTORIA OBENG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 703-402-2047
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------