Basic Information
| Provider Information | |||||||||
| NPI: | 1538473418 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CSP NOVA LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DULLES HEALTH & REHAB CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5372 FALLOWATER LN | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240180907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407258910 | ||||||||
| FaxNumber: | 5407258914 | ||||||||
| Practice Location | |||||||||
| Address1: | 2978 CENTREVILLE ROAD | ||||||||
| Address2: | |||||||||
| City: | HERNDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201716253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039345000 | ||||||||
| FaxNumber: | 7039345092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2010 | ||||||||
| LastUpdateDate: | 08/31/2021 | ||||||||
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| AuthorizedOfficialLastName: | ALESANTRINO | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5407258910 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH2594 | VA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 004951743 | 05 | VA | MEDICAID |