Healthcare Provider Details

I. General information

NPI: 1952126518
Provider Name (Legal Business Name): KEYSTONE RESIDENTIAL LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4528 FORESTBURG LN
TRIANGLE VA
22172-1705
US

IV. Provider business mailing address

4528 FORESTBURG LN
TRIANGLE VA
22172-1705
US

V. Phone/Fax

Practice location:
  • Phone: 571-243-8164
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: JACQUELINE COLEMAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 571-243-8164