Healthcare Provider Details

I. General information

NPI: 1902299985
Provider Name (Legal Business Name): SHANGRI-LA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2015
Last Update Date: 03/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 BUTOR RD
NORTH PRINCE GEORGE VA
23860-7429
US

IV. Provider business mailing address

PO BOX 1014
PRINCE GEORGE VA
23875-0961
US

V. Phone/Fax

Practice location:
  • Phone: 804-541-3589
  • Fax:
Mailing address:
  • Phone: 804-541-3589
  • 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 Number2473
License Number StateVA

VIII. Authorized Official

Name: MS. LORETTA FAULKNIER
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 804-541-3589