Provider Demographics
NPI:1972238673
Name:M.A.K. SUPERIOR HOME HEALTH LLC
Entity Type:Organization
Organization Name:M.A.K. SUPERIOR HOME HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-CEO
Authorized Official - Prefix:
Authorized Official - First Name:KADIATU
Authorized Official - Middle Name:
Authorized Official - Last Name:SESAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-807-9104
Mailing Address - Street 1:13601 OFFICE PL STE 102A
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-4213
Mailing Address - Country:US
Mailing Address - Phone:804-807-9104
Mailing Address - Fax:571-520-0356
Practice Address - Street 1:13601 OFFICE PL STE 102A
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-4213
Practice Address - Country:US
Practice Address - Phone:804-807-9104
Practice Address - Fax:571-520-0356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-18
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No251J00000XAgenciesNursing CareGroup - Multi-Specialty
No385H00000XRespite Care FacilityRespite CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1972238673OtherCOMMONWEALTH OF VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES,PROVIDER ENRO
VA1972238673Medicaid