Provider Demographics
NPI:1891044657
Name:DRYNACHAN LLC
Entity type:Organization
Organization Name:DRYNACHAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-449-2928
Mailing Address - Street 1:14121 PARKE LONG CT
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-1647
Mailing Address - Country:US
Mailing Address - Phone:571-449-3585
Mailing Address - Fax:
Practice Address - Street 1:14121 PARKE LONG CT
Practice Address - Street 2:SUITE 201
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1647
Practice Address - Country:US
Practice Address - Phone:571-449-3585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-07
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1891044657Medicaid
IN300001898Medicaid
IL1891055657Medicaid
MO500040770Medicaid
FL18159900Medicaid
VA1991044657Medicaid
GA003185092AMedicaid
SCGP7738Medicaid