Healthcare Provider Details

I. General information

NPI: 1073058673
Provider Name (Legal Business Name): MOUNTAIN VIEW RESIDENTIAL INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2017
Last Update Date: 01/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1143 GOLF VIEW CT
HUDDLESTON VA
24104-4303
US

IV. Provider business mailing address

1143 GOLF VIEW CT
HUDDLESTON VA
24104-4303
US

V. Phone/Fax

Practice location:
  • Phone: 540-297-4039
  • Fax:
Mailing address:
  • Phone: 540-297-4039
  • 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 Number250801001
License Number StateVA

VIII. Authorized Official

Name: MRS. TRACEY MASHELL ANDERSON
Title or Position: DIRECTOR
Credential: M.A.
Phone: 540-297-4039