=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215650270
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RAHMA GROUP HOME LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2022
-----------------------------------------------------
Last Update Date | 09/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4609 GUINEA RD
-----------------------------------------------------
City | ANNANDALE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22003-3956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-282-6389
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4609 GUINEA RD
-----------------------------------------------------
City | ANNANDALE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22003-3956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-282-6389
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | IDIL A JAMA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 703-282-6389
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------