Healthcare Provider Details

I. General information

NPI: 1487730008
Provider Name (Legal Business Name): ROANENTERPRISES, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5612 VININGS DR APT 106-7
RICHMOND VA
23234-4690
US

IV. Provider business mailing address

PO BOX 322
RICHMOND VA
23218-0322
US

V. Phone/Fax

Practice location:
  • Phone: 804-714-0737
  • Fax: 804-622-4894
Mailing address:
  • Phone: 804-349-6382
  • Fax: 804-622-4894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberSS-280-06
License Number StateVA

VIII. Authorized Official

Name: MR. MARVIN VAN ROANE
Title or Position: PRESIDENT/CEO
Credential:
Phone: 804-349-6382