Provider Demographics
| NPI: | 1366267304 |
|---|---|
| Name: | LIFE TREE CARE CENTER INC |
| Entity type: | Organization |
| Organization Name: | LIFE TREE CARE CENTER INC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | PRESIDENT |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | KYONG |
| Authorized Official - Middle Name: | HOON |
| Authorized Official - Last Name: | KO |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | PMP |
| Authorized Official - Phone: | 434-212-0460 |
| Mailing Address - Street 1: | 11240 WAPLES MILL RD STE 201 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | FAIRFAX |
| Mailing Address - State: | VA |
| Mailing Address - Zip Code: | 22030-6078 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 434-212-0460 |
| Mailing Address - Fax: | 703-570-7668 |
| Practice Address - Street 1: | 11240 WAPLES MILL RD STE 201 |
| Practice Address - Street 2: | |
| Practice Address - City: | FAIRFAX |
| Practice Address - State: | VA |
| Practice Address - Zip Code: | 22030-6078 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 434-212-0460 |
| Practice Address - Fax: | 703-570-7668 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2024-11-15 |
| Last Update Date: | 2024-11-15 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 261QA0600X | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care | |
| No | 163WH0200X | Nursing Service Providers | Registered Nurse | Home Health | Group - Multi-Specialty |
| No | 251G00000X | Agencies | Hospice Care, Community Based | ||
| No | 251J00000X | Agencies | Nursing Care | ||
| No | 253Z00000X | Agencies | In Home Supportive Care | ||
| No | 261QR0400X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | |
| No | 261QU0200X | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | |
| No | 310400000X | Nursing & Custodial Care Facilities | Assisted Living Facility | ||
| No | 3104A0625X | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Mental Illness | |
| No | 3104A0630X | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Behavioral Disturbances | |
| No | 261QP2000X | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | |
| No | 311ZA0620X | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home | |
| No | 313M00000X | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | ||
| No | 314000000X | Nursing & Custodial Care Facilities | Skilled Nursing Facility | ||
| No | 3140N1450X | Nursing & Custodial Care Facilities | Skilled Nursing Facility | Nursing Care, Pediatric |
