Provider Demographics
NPI:1912396458
Name:GREEN HOME CARE AGENCY, LLC
Entity Type:Organization
Organization Name:GREEN HOME CARE AGENCY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:KHALIDAH
Authorized Official - Middle Name:A
Authorized Official - Last Name:SEDIQ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-439-7382
Mailing Address - Street 1:2562 MIRANDA CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-5175
Mailing Address - Country:US
Mailing Address - Phone:703-439-7382
Mailing Address - Fax:
Practice Address - Street 1:2562 MIRANDA CT
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-5175
Practice Address - Country:US
Practice Address - Phone:703-439-7382
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA372600000X251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA47-2855057OtherIRS