MEDICARE: SUBON HOME CARE 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	385H00000X	Respite Care
2	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1730959248
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUBON HOME CARE AGENCY LLC

Provider Business Mailing Address
First Line	:	5602 TRUITT FARM CT
Second Line	:
City	:	CENTREVILLE
State	:	VA
Zip	:	20120-5406
Country	:	US
Telephone Number	:	571-470-7541
Fax Number	:	571-444-6786

Provider Business Practice Location Address
First Line	:	14325 WILLARD RD UNIT D
Second Line	:
City	:	CHANTILLY
State	:	VA
Zip	:	20151-2110
Country	:	US
Telephone Number	:	571-470-7541
Fax Number	:	571-444-6786

Authorized Official
Title or Position	:	OWNER / ADMINISTRATOR
Name	:	SUSAN KAITESI
Credential	:
Telephone Number	:	859-361-9000

Provider Enumeration Date	:	01/05/2024
Last Update Date	:	05/13/2025

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Directions to “SUBON HOME CARE AGENCY LLC ” Practice Location

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