Healthcare Provider Details

I. General information

NPI: 1205184157
Provider Name (Legal Business Name): POSITIVE LIVING CHOICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2012
Last Update Date: 08/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1735 MONTICELLO ST
PETERSBURG VA
23805-1640
US

IV. Provider business mailing address

PO BOX 303
COLONIAL HEIGHTS VA
23834-0303
US

V. Phone/Fax

Practice location:
  • Phone: 704-726-7780
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. CARLOS WILKINS
Title or Position: CO-OWNER
Credential:
Phone: 804-647-4358