Provider Demographics
NPI:1124374061
Name:LONE JACK HOLDINGS, INC.
Entity Type:Organization
Organization Name:LONE JACK HOLDINGS, INC.
Other - Org Name:BRIGHTSTAR OF FAIRFAX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WITHERS
Authorized Official - Last Name:MASSIE
Authorized Official - Suffix:IV
Authorized Official - Credentials:
Authorized Official - Phone:630-699-5900
Mailing Address - Street 1:10517 BRADDOCK RD STE C
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-2275
Mailing Address - Country:US
Mailing Address - Phone:703-267-2380
Mailing Address - Fax:
Practice Address - Street 1:10517 BRADDOCK RD STE C
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22032-2275
Practice Address - Country:US
Practice Address - Phone:703-267-2380
Practice Address - Fax:703-267-2384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-30
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0OtherNONE