Provider Demographics
NPI:1457656084
Name:DOMAIN MEDICAL HOME HEALTH & STAFFING, INC.
Entity Type:Organization
Organization Name:DOMAIN MEDICAL HOME HEALTH & STAFFING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GIBSON
Authorized Official - Middle Name:
Authorized Official - Last Name:ERHUNMWUNSE
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:703-299-4949
Mailing Address - Street 1:2121 EISENHOWER AVE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-4698
Mailing Address - Country:US
Mailing Address - Phone:703-299-4949
Mailing Address - Fax:703-299-6699
Practice Address - Street 1:2121 EISENHOWER AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-4698
Practice Address - Country:US
Practice Address - Phone:703-299-4949
Practice Address - Fax:703-299-6699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-12
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAHC0-11711251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health