Provider Demographics
NPI:1528449055
Name:MYPOTENTIAL VIRGINIA, LLC
Entity type:Organization
Organization Name:MYPOTENTIAL VIRGINIA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:SR
Authorized Official - Credentials:CPA
Authorized Official - Phone:301-354-2714
Mailing Address - Street 1:2301 RESEARCH BLVD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3204
Mailing Address - Country:US
Mailing Address - Phone:301-354-2710
Mailing Address - Fax:
Practice Address - Street 1:320 WESTSIDE STATION DR
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2839
Practice Address - Country:US
Practice Address - Phone:540-450-0343
Practice Address - Fax:540-723-0858
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NATIONAL LUTERAN HOME FOR THE AGED, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-10
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAHCO-151094251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health