Provider Demographics
NPI:1912032012
Name:INOVA HEALTH SYSTEM SERVICES
Entity Type:Organization
Organization Name:INOVA HEALTH SYSTEM SERVICES
Other - Org Name:COMMONWEALTH CARE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:SENIOR ADMINSTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-279-4252
Mailing Address - Street 1:2990 TELESTAR CT
Mailing Address - Street 2:SUITE 3LT
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-1207
Mailing Address - Country:US
Mailing Address - Phone:571-423-5747
Mailing Address - Fax:571-423-5703
Practice Address - Street 1:4315 CHAIN BRIDGE RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-3061
Practice Address - Country:US
Practice Address - Phone:703-934-5000
Practice Address - Fax:703-934-5092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VANH2594314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004951743Medicaid
VA004960131Medicaid
VA004960131Medicaid