Provider Demographics
NPI:1740430263
Name:COMMONWEALTH HEALTHCARE, LLC
Entity type:Organization
Organization Name:COMMONWEALTH HEALTHCARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:R
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:857-331-6271
Mailing Address - Street 1:1234 CHESTNUT ST STE 114
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02464-1491
Mailing Address - Country:US
Mailing Address - Phone:434-977-9711
Mailing Address - Fax:434-235-4142
Practice Address - Street 1:500 FAULCONER DR STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-4972
Practice Address - Country:US
Practice Address - Phone:434-970-7776
Practice Address - Fax:434-970-7773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-19
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1740430263Medicaid
VA1740430263Medicaid