MEDICARE: COMMUNITY RESIDENCES, 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	315P00000X	Intellectual Disabilities Intermediate Care Facility	05801001	VA

General Provider Information

NPI Number	:	1972751873
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY RESIDENCES, INC.

Provider Business Mailing Address
First Line	:	14160 NEWBROOK DR
Second Line	:
City	:	CHANTILLY
State	:	VA
Zip	:	20151-2297
Country	:	US
Telephone Number	:	703-842-2333
Fax Number	:	703-842-2311

Provider Business Practice Location Address
First Line	:	2332 N RIVERSIDE DR
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23225-2542
Country	:	US
Telephone Number	:	703-842-2333
Fax Number	:	703-842-2311

Authorized Official
Title or Position	:	VP ADMIN, CHIEF FINANCIAL OFFICER
Name	:	TERRY HURLEY
Credential	:
Telephone Number	:	703-842-2321

Provider Enumeration Date	:	09/04/2008
Last Update Date	:	01/09/2018

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