Healthcare Provider Details

I. General information

NPI: 1043010945
Provider Name (Legal Business Name): NIYA SUPPLIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2025
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1262 PARKWOOD AVE
RICHMOND VA
23220-5440
US

IV. Provider business mailing address

11357 NUCKLOS RD PMB 191
GLEN ALLEN VA
23059
US

V. Phone/Fax

Practice location:
  • Phone: 919-888-0654
  • Fax:
Mailing address:
  • Phone: 919-888-0654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. HANIA MAE LITAKER
Title or Position: HEALTH ADMINISTRATOR
Credential:
Phone: 919-888-0654