MEDICARE: DOMINION EVERCARE HOME AGENCY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1144171364
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOMINION EVERCARE HOME AGENCY LLC

Provider Business Mailing Address
First Line	:	12138 GREY OAKS PARK RD
Second Line	:
City	:	GLEN ALLEN
State	:	VA
Zip	:	23059-5781
Country	:	US
Telephone Number	:	929-990-7030
Fax Number	:

Provider Business Practice Location Address
First Line	:	12138 GREY OAKS PARK RD
Second Line	:
City	:	GLEN ALLEN
State	:	VA
Zip	:	23059-5781
Country	:	US
Telephone Number	:	929-990-7030
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ALBERT KIM
Credential	:
Telephone Number	:	929-990-7030

Provider Enumeration Date	:	02/04/2026
Last Update Date	:	02/04/2026

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