| NPI | 1073069399 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CLARENCE RUSSELL Owner 757-567-0923 |
| Organization Subpart ? | No |
| Primary Taxonomy | 320900000X Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities (Licence: VA 2121) |
| Enumeration Date | 2016-08-28 |
| Last Update Date | 2016-08-28 |