MEDICARE: CLEARR VISSION SUPPORT SERVICES, INC

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	792-02-001	VA

General Provider Information

NPI Number	:	1952850380
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEARR VISSION SUPPORT SERVICES, INC

Provider Business Mailing Address
First Line	:	4220 OAKLEYS CT
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23223-5974
Country	:	US
Telephone Number	:	804-677-8307
Fax Number	:	804-328-1793

Provider Business Practice Location Address
First Line	:	1323 ASBURY RD
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23229-5305
Country	:	US
Telephone Number	:	804-677-8307
Fax Number	:	804-328-1793

Authorized Official
Title or Position	:	CEO
Name	:	MR. DERWIN L HICKMAN SR.
Credential	:
Telephone Number	:	804-677-8307

Provider Enumeration Date	:	09/27/2016
Last Update Date	:	09/27/2016

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