Provider Demographics
NPI:1659935880
Name:WOODBRIDGE SH LESSEE, LLC
Entity Type:Organization
Organization Name:WOODBRIDGE SH LESSEE, LLC
Other - Org Name:ARBOR TERRACE PRINCE WILLIAM COMMONS
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-721-8801
Mailing Address - Street 1:14080 CENTRAL LOOP
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193
Mailing Address - Country:US
Mailing Address - Phone:703-721-8801
Mailing Address - Fax:571-285-2274
Practice Address - Street 1:14080 CENTRAL LOOP
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-1438
Practice Address - Country:US
Practice Address - Phone:703-721-8801
Practice Address - Fax:571-285-2274
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WOODBRIDGE SH LESSEE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-04-23
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAALF1105083OtherASSISTED LIVING AND MEMORY CARE