Healthcare Provider Details

I. General information

NPI: 1184180085
Provider Name (Legal Business Name): HOTEP HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2019
Last Update Date: 02/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5905 DUNKIRK ST
PORTSMOUTH VA
23703-3129
US

IV. Provider business mailing address

5905 DUNKIRK ST
PORTSMOUTH VA
23703-3129
US

V. Phone/Fax

Practice location:
  • Phone: 757-652-3058
  • Fax:
Mailing address:
  • Phone: 757-652-3058
  • 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. DARIO L WATERS
Title or Position: ADMINISTRATOR
Credential:
Phone: 757-652-3058