Healthcare Provider Details

I. General information

NPI: 1619968112
Provider Name (Legal Business Name): SENTARA LIFE CARE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 NEWTOWN RD
VIRGINIA BEACH VA
23462-1683
US

IV. Provider business mailing address

251 S NEWTOWN RD
NORFOLK VA
23502-5718
US

V. Phone/Fax

Practice location:
  • Phone: 757-502-7800
  • Fax: 757-502-7801
Mailing address:
  • Phone: 757-892-5400
  • Fax: 757-892-5401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License NumberELO 2004-249
License Number StateVA

VIII. Authorized Official

Name: BRUCE ROBERTSON
Title or Position: VICE PRESIDENT SENTARA LIFE CARE
Credential:
Phone: 757-892-5400