1174782304 NPI number — PROVIDING EQUAL OPPORTUNITY PROGRESSIVE LIVING ENVIRONMENTS, LLC

Table of content: (NPI 1174782304)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174782304 NPI number — PROVIDING EQUAL OPPORTUNITY PROGRESSIVE LIVING ENVIRONMENTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDING EQUAL OPPORTUNITY PROGRESSIVE LIVING ENVIRONMENTS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
P.E.O.P.L.E., LLC (ACRONYMN FOR COMPANY NAME)
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174782304
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10301 KUPPERTON CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREDERICKSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22408-8054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-373-8096
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10301 KUPPERTON CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREDERICKSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22408-8054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-373-8096
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DAMERON
Authorized Official First Name:
JUSTIN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/DIRECTOR OF FINANCE
Authorized Official Telephone Number:
540-373-8096

Provider Taxonomy Codes

  • Taxonomy code: 320900000X , with the licence number:  112501001 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 112501001 . This is a "DEPARTMENT OF MENTAL HEALTH MENTAL RETARDATION AND SUBSTANCE ABUSE SERVICES" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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