MEDICARE: AC SUPPORT SYSTEMS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	1483-01-001	VA

General Provider Information

NPI Number	:	1609178656
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AC SUPPORT SYSTEMS, LLC

Provider Business Mailing Address
First Line	:	3420 PLUM CRES
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23453-2815
Country	:	US
Telephone Number	:	757-408-9760
Fax Number	:	757-353-4424

Provider Business Practice Location Address
First Line	:	4412 GLEN LAKE PATH
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-4714
Country	:	US
Telephone Number	:	757-408-9760
Fax Number	:	757-353-4424

Authorized Official
Title or Position	:	OWNER
Name	:	MR. RIZAL L CRUZ
Credential	:
Telephone Number	:	757-408-9760

Provider Enumeration Date	:	11/24/2010
Last Update Date	:	11/24/2010

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