Provider Demographics
NPI:1093105140
Name:AGAP CONSUMER DIRECTED SERVICES, LLC
Entity Type:Organization
Organization Name:AGAP CONSUMER DIRECTED SERVICES, LLC
Other - Org Name:GOOD OLD DAYS - AT HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:ANITA
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:804-723-1374
Mailing Address - Street 1:PO BOX 951
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23111-0951
Mailing Address - Country:US
Mailing Address - Phone:804-723-1374
Mailing Address - Fax:804-591-0384
Practice Address - Street 1:8090 MECHANICSVILLE TPKE STE F
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23111-1204
Practice Address - Country:US
Practice Address - Phone:804-723-1374
Practice Address - Fax:804-591-0384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-28
Last Update Date:2018-04-25
Deactivation Date:2018-04-24
Deactivation Code:
Reactivation Date:2018-04-25
Provider Licenses
StateLicense IDTaxonomies
VA171M00000X
VAHCO-171518253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0164177690Medicaid