Healthcare Provider Details

I. General information

NPI: 1922184282
Provider Name (Legal Business Name): COMMUNITY RESIDENCES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2006
Last Update Date: 01/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1612 N MCKINLEY RD
ARLINGTON VA
22205-2237
US

IV. Provider business mailing address

14160 NEWBROOK DR
CHANTILLY VA
20151-2297
US

V. Phone/Fax

Practice location:
  • Phone: 703-842-2333
  • Fax: 703-842-2311
Mailing address:
  • Phone: 703-842-2333
  • Fax: 703-842-2311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number05801001
License Number StateVA

VIII. Authorized Official

Name: MARY JAYNE PANEK
Title or Position: PROJECT IMPLEMENTATION MANAGER
Credential:
Phone: 703-842-2327