Healthcare Provider Details

I. General information

NPI: 1881813517
Provider Name (Legal Business Name): SMITH'S HOME FOR ADULTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16069 MARTINSVILLE HWY
AXTON VA
24054-1973
US

IV. Provider business mailing address

16069 MARTINSVILLE HWY
AXTON VA
24054-1973
US

V. Phone/Fax

Practice location:
  • Phone: 434-685-1778
  • Fax: 434-685-2036
Mailing address:
  • Phone: 434-685-1778
  • Fax: 434-685-2036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License NumberRO07105
License Number StateVA

VIII. Authorized Official

Name: MR. KERRY GLENN SMITH
Title or Position: ADMINISTRATOR- PRESIDENT
Credential: LICENSED
Phone: 434-685-1778