Basic Information
| Provider Information | |||||||||
| NPI: | 1912032012 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INOVA HEALTH SYSTEM SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | COMMONWEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2990 TELESTAR CT | ||||||||
| Address2: | SUITE 3LT | ||||||||
| City: | FALLS CHURCH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220421207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5714235747 | ||||||||
| FaxNumber: | 5714235703 | ||||||||
| Practice Location | |||||||||
| Address1: | 4315 CHAIN BRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220303061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039345000 | ||||||||
| FaxNumber: | 7039345092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 11/18/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAGER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR ADMINSTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7032794252 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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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 | 004960131 | 05 | VA | MEDICAID |