Healthcare Provider Details

I. General information

NPI: 1235814765
Provider Name (Legal Business Name): OUR LOVED ONES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2023
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4821 PRINCE GEORGE DR ABC
PRINCE GEORGE VA
23875-2762
US

IV. Provider business mailing address

4821 PRINCE GEORGE DR. ABC
PRINCE GEORGE VA
23875-2762
US

V. Phone/Fax

Practice location:
  • Phone: 804-878-6636
  • Fax:
Mailing address:
  • Phone: 804-668-5193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NICOLE JONES-SHENJOBI
Title or Position: OWNER/DIRECTOR
Credential: RN, BSN
Phone: 804-663-5193