Healthcare Provider Details

I. General information

NPI: 1013364512
Provider Name (Legal Business Name): FAITHFUL NUBIAN SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 05/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 HUSTINGS LN UNIT E
NEWPORT NEWS VA
23608-2807
US

IV. Provider business mailing address

410 HUSTINGS LN UNIT E
NEWPORT NEWS VA
23608-2807
US

V. Phone/Fax

Practice location:
  • Phone: 757-491-3941
  • Fax: 757-325-8283
Mailing address:
  • Phone: 757-491-3941
  • Fax: 757-325-8283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: SURENA GLOVER
Title or Position: OWNER
Credential:
Phone: 757-419-3941