Healthcare Provider Details

I. General information

NPI: 1275328585
Provider Name (Legal Business Name): GREENBRIAR PLACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2025
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 DIGGS DR
HAMPTON VA
23666-1757
US

IV. Provider business mailing address

115 DIGGS DR
HAMPTON VA
23666-1757
US

V. Phone/Fax

Practice location:
  • Phone: 757-775-0113
  • Fax:
Mailing address:
  • Phone: 757-775-0113
  • Fax:

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 State

VIII. Authorized Official

Name: MS. JENNINE ROCHELLE BOOTH
Title or Position: MANAGER/ ADMINISTRATOR
Credential:
Phone: 757-775-0113