Healthcare Provider Details

I. General information

NPI: 1972675908
Provider Name (Legal Business Name): COMMUNITY RESIDENCES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 01/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 NORTH JACKSON STREET CRI JACKSON STREET ICF
ARLINGTON VA
22201
US

IV. Provider business mailing address

14160 NEWBROOK DR
CHANTILLY VA
20151-2297
US

V. Phone/Fax

Practice location:
  • Phone: 703-842-2333
  • Fax:
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: TERRY WILLIAM HURLEY
Title or Position: VP OF ADMINISTRATION/CFO
Credential:
Phone: 703-842-2321