Provider Demographics
NPI:1366678518
Name:ALLEGIANCE GROUP DIVERSIFIED, INC.
Entity Type:Organization
Organization Name:ALLEGIANCE GROUP DIVERSIFIED, INC.
Other - Org Name:ALLEGIANCE GROUP AT HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:DENEEN
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-615-1974
Mailing Address - Street 1:101 E HOLLY AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20164-5402
Mailing Address - Country:US
Mailing Address - Phone:703-615-1974
Mailing Address - Fax:703-738-7009
Practice Address - Street 1:101 E HOLLY AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-5402
Practice Address - Country:US
Practice Address - Phone:703-615-1974
Practice Address - Fax:703-738-7009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-02
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAB911896251E00000X
VAB911899332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAB911884OtherBUSINESS PROFESSIONAL AND OCCUPATIONAL LICENSE
VAB911899OtherBUSINESS PROFESSIONAL AND OCCUPATIONAL LICENSE
VAB911896OtherBUSINESS PROFESSIONAL AND OCCUPATIONAL LICENSE