Healthcare Provider Details

I. General information

NPI: 1376856930
Provider Name (Legal Business Name): ESHCOL BROOK HOMES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2010
Last Update Date: 07/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 LONGVIEW LN
GALAX VA
24333-2154
US

IV. Provider business mailing address

747 LONGVIEW LANE
GALAX VA
24333-2154
US

V. Phone/Fax

Practice location:
  • Phone: 276-728-3121
  • Fax:
Mailing address:
  • Phone: 276-728-3121
  • 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 Number1282-01-001
License Number StateVA

VIII. Authorized Official

Name: MR. GREGORY L FIELDS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 276-728-3121