Healthcare Provider Details

I. General information

NPI: 1083437941
Provider Name (Legal Business Name): PERSEVERE RESIDENTIAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2024
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3446 CHELSEA DR
WOODBRIDGE VA
22192-4358
US

IV. Provider business mailing address

3446 CHELSEA DR
WOODBRIDGE VA
22192-4358
US

V. Phone/Fax

Practice location:
  • Phone: 703-587-8061
  • Fax: 571-285-4230
Mailing address:
  • Phone: 703-587-8061
  • Fax: 571-285-4230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: CANDIDA EYAMIDAE COLE
Title or Position: CEO
Credential:
Phone: 703-703-8061