Healthcare Provider Details

I. General information

NPI: 1174348379
Provider Name (Legal Business Name): CIVITAS PARA VITA LIMITED LIABILITY CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2024
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 IRON BRIDGE RD
LAWRENCEVILLE VA
23868-3937
US

IV. Provider business mailing address

875 IRON BRIDGE RD
LAWRENCEVILLE VA
23868-3937
US

V. Phone/Fax

Practice location:
  • Phone: 434-917-1211
  • Fax:
Mailing address:
  • Phone: 434-917-1211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: JESSICA SIOTIA BEATRICE HURDLE
Title or Position: OWNER
Credential:
Phone: 434-917-1211