Provider Demographics
NPI:1164912622
Name:AGING WELL HEALTH AND WELLNES
Entity Type:Organization
Organization Name:AGING WELL HEALTH AND WELLNES
Other - Org Name:AGING WELL HEALTHCARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:C
Authorized Official - Last Name:GUNN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:804-869-5045
Mailing Address - Street 1:670 N CREEK RD
Mailing Address - Street 2:
Mailing Address - City:APPOMATTOX
Mailing Address - State:VA
Mailing Address - Zip Code:24522-8531
Mailing Address - Country:US
Mailing Address - Phone:804-869-5045
Mailing Address - Fax:
Practice Address - Street 1:7631B RICHMOND HWY
Practice Address - Street 2:
Practice Address - City:APPOMATTOX
Practice Address - State:VA
Practice Address - Zip Code:24522-8679
Practice Address - Country:US
Practice Address - Phone:804-869-5045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-10
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 251B00000X, 251E00000X, 3747P1801X
VA385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No251E00000XAgenciesHome HealthGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No385H00000XRespite Care FacilityRespite CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1164912622Medicaid