Healthcare Provider Details

I. General information

NPI: 1588491013
Provider Name (Legal Business Name): 412 RESIDENTIAL LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2024
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3807 CANNINGTON DR
NORTH CHESTERFIELD VA
23237-1968
US

IV. Provider business mailing address

3807 CANNINGTON DR
NORTH CHESTERFIELD VA
23237-1968
US

V. Phone/Fax

Practice location:
  • Phone: 804-248-0375
  • Fax:
Mailing address:
  • Phone: 804-248-0375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. ZAIRE CARTER
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 804-248-0375