Healthcare Provider Details

I. General information

NPI: 1184174864
Provider Name (Legal Business Name): INTREPID OF VIRGINIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 11/09/2022
Certification Date: 11/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 MARKET ST STE 2
ONANCOCK VA
23417-4233
US

IV. Provider business mailing address

14841 DALLAS PKWY STE 625
DALLAS TX
75254-7641
US

V. Phone/Fax

Practice location:
  • Phone: 757-356-4182
  • Fax: 757-787-8430
Mailing address:
  • Phone: 214-445-3750
  • Fax: 214-445-3994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License NumberHSP-16232
License Number StateVA

VIII. Authorized Official

Name: ROBERT PARKER
Title or Position: CCO
Credential:
Phone: 214-445-3750