Provider Demographics
NPI:1497761175
Name:MOUNT VERNON NURSING CENTER ASSOCIATES, LLLP
Entity Type:Organization
Organization Name:MOUNT VERNON NURSING CENTER ASSOCIATES, LLLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:K
Authorized Official - Last Name:DEMARIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-360-4000
Mailing Address - Street 1:8111 TIS WELL DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22306-3211
Mailing Address - Country:US
Mailing Address - Phone:703-360-4000
Mailing Address - Fax:703-360-9325
Practice Address - Street 1:8111 TIS WELL DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-3211
Practice Address - Country:US
Practice Address - Phone:703-360-4000
Practice Address - Fax:703-360-9325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VANH2634313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004952111Medicaid
VA004952111Medicaid