Provider Demographics
NPI:1417373622
Name:CLASSIC CAREGIVERS
Entity type:Organization
Organization Name:CLASSIC CAREGIVERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:KERSHES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-201-4579
Mailing Address - Street 1:6506 ROCK CRYSTAL DR
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:VA
Mailing Address - Zip Code:20124-2520
Mailing Address - Country:US
Mailing Address - Phone:877-201-4579
Mailing Address - Fax:703-520-2802
Practice Address - Street 1:6506 ROCK CRYSTAL DR
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:VA
Practice Address - Zip Code:20124-2520
Practice Address - Country:US
Practice Address - Phone:877-201-4579
Practice Address - Fax:703-520-2802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-12
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAHCO151201251E00000X
253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1355991OtherFAIRFAX COUNTY BUSINESS, PROFESSIONAL & OCCUPATIONAL LICENSE
VAHCO151201OtherVDOH