Healthcare Provider Details

I. General information

NPI: 1104911122
Provider Name (Legal Business Name): CHILD OF GOD GROUP HOMESLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 RIDGEWAY AVE
HAMPTON VA
23661-1413
US

IV. Provider business mailing address

633 RIDGEWAY AVE
HAMPTON VA
23661-1413
US

V. Phone/Fax

Practice location:
  • Phone: 757-727-7807
  • Fax: 757-727-9690
Mailing address:
  • Phone: 757-727-7807
  • Fax: 757-727-9690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. KENDRIC MCKNIGHT
Title or Position: ADMINISTRATOR
Credential:
Phone: 757-810-4711