MEDICARE: EASTERN GROVE SUPPORT LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QM0850X	Adult Mental Health Clinic/Center
2	251S00000X	Community/Behavioral Health Agency
3	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
4	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1700694320
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTERN GROVE SUPPORT LLC

Provider Business Mailing Address
First Line	:	355 CRAWFORD ST
Second Line	:
City	:	PORTSMOUTH
State	:	VA
Zip	:	23704-2816
Country	:	US
Telephone Number	:	757-392-9337
Fax Number	:

Provider Business Practice Location Address
First Line	:	355 CRAWFORD ST
Second Line	:
City	:	PORTSMOUTH
State	:	VA
Zip	:	23704-2816
Country	:	US
Telephone Number	:	833-774-9633
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	KEENEN MAPP
Credential	:
Telephone Number	:	833-774-9633

Provider Enumeration Date	:	12/28/2024
Last Update Date	:	03/18/2026

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