=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750547444
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRINCE WILLIAM AREA AGENCY ON AGING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2008
-----------------------------------------------------
Last Update Date | 12/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5 COUNTY COMPLEX CT SUITE 240
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22192-9200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-792-6439
-----------------------------------------------------
Fax | 703-792-4734
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 COUNTY COMPLEX CT SUITE 240
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22192-9200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-792-6439
-----------------------------------------------------
Fax | 703-792-4734
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | SARAH HENRY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 703-792-6439
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number | 0087303001
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------