Healthcare Provider Details

I. General information

NPI: 1093649519
Provider Name (Legal Business Name): SHEPHERD RESIDENCE OF VIRGINIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17365 AVION SQ
ROUND HILL VA
20141-2492
US

IV. Provider business mailing address

17365 AVION SQ
ROUND HILL VA
20141-2492
US

V. Phone/Fax

Practice location:
  • Phone: 703-926-4710
  • Fax:
Mailing address:
  • Phone: 703-926-4710
  • 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 TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. GEORGE CAULKER
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 703-926-4710