Healthcare Provider Details

I. General information

NPI: 1285553933
Provider Name (Legal Business Name): COACH K CARES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2613 ELON DR
VIRGINIA BEACH VA
23454-4355
US

IV. Provider business mailing address

2613 ELON DR
VIRGINIA BEACH VA
23454-4355
US

V. Phone/Fax

Practice location:
  • Phone: 757-240-7467
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: ISHMAEL KAKOUCHE
Title or Position: OWNER/QIDP
Credential:
Phone: 757-240-7467