Healthcare Provider Details

I. General information

NPI: 1790226215
Provider Name (Legal Business Name): B & R SUPPORTIVE LIVING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2017
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5752 ANDREA DR NORFOLK, VA 23518
NORFOLK VA
23518-5743
US

IV. Provider business mailing address

5752 ANDREA DR NORFOLK, VA 23518
NORFOLK VA
23518-5743
US

V. Phone/Fax

Practice location:
  • Phone: 757-367-1961
  • Fax: 757-499-6323
Mailing address:
  • Phone: 757-367-1961
  • Fax: 757-499-6323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. WYNTER WYNETTE RIDDICK
Title or Position: OWNER
Credential: CEO
Phone: 757-367-1961