Provider Demographics
NPI:1235536608
Name:GREENFIELD ASSISTED LIVING OF STAFFORD LLC
Entity Type:Organization
Organization Name:GREENFIELD ASSISTED LIVING OF STAFFORD LLC
Other - Org Name:GREENFIELD ASSISTED LIVING OF STAFFORD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MATHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:PEPONIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-962-9125
Mailing Address - Street 1:30 KINGS CREST DRIVE
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554
Mailing Address - Country:US
Mailing Address - Phone:540-288-9353
Mailing Address - Fax:540-288-8834
Practice Address - Street 1:6312 SEVEN CORNERS CENTER #161
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22044
Practice Address - Country:US
Practice Address - Phone:703-962-9125
Practice Address - Fax:703-237-5609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-01
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAWLO-05-1103730310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility