Healthcare Provider Details

I. General information

NPI: 1467788992
Provider Name (Legal Business Name): CAVALIER CONGREGATE CONSORTIUM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2009
Last Update Date: 10/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 ROSE HILL DR
CHARLOTTESVILLE VA
22903-5235
US

IV. Provider business mailing address

631 ROSE HILL DR
CHARLOTTESVILLE VA
22903-5235
US

V. Phone/Fax

Practice location:
  • Phone: 434-906-4565
  • Fax:
Mailing address:
  • Phone: 434-906-4565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number1183-001
License Number StateVA

VIII. Authorized Official

Name: MS. DANA-CARMEN DEL TORO
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 434-293-5984