Healthcare Provider Details

I. General information

NPI: 1144551144
Provider Name (Legal Business Name): MERRYFIELD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2010
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 HORSE MOUNTAIN VW
COVINGTON VA
24426-6402
US

IV. Provider business mailing address

205 E HAWTHORNE ST
COVINGTON VA
24426-1620
US

V. Phone/Fax

Practice location:
  • Phone: 540-962-7732
  • Fax:
Mailing address:
  • Phone: 540-965-2135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number127-01-011
License Number StateVA

VIII. Authorized Official

Name: EDWINA ANDREWS
Title or Position: REIMBURSEMENT MANAGER
Credential:
Phone: 540-965-2135