=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336487537
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OCTOBER VENTURES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2013
-----------------------------------------------------
Last Update Date | 06/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3683 FETTLER PARK DR
-----------------------------------------------------
City | DUMFRIES
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22025-2049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-490-8003
-----------------------------------------------------
Fax | 703-995-4585
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3683 FETTLER PARK DR
-----------------------------------------------------
City | DUMFRIES
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22025-2049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-490-8003
-----------------------------------------------------
Fax | 703-995-4585
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANIM ADDO SAMPONG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 703-490-8003
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | HCO 13919
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------