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General NPI Number Information
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NPI Number | 1003697392
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Entity Type | Organization
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Legal Business Name | REVAMP SUPPORT RESIDENTIAL SERVICES LLP
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Dates
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Enumeration Date | 10/11/2023
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Last Update Date | 10/11/2023
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Provider Practice Location Address
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Address Line | 2851 HEADWAY DR
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City | WOODBRIDGE
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State | VA
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Zip | 22191-6042
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Country | US
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Telephone | 202-820-6698
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Fax |
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Provider Business Mailing Address
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Address Line | 2851 HEADWAY DR
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City | WOODBRIDGE
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State | VA
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Zip | 22191-6042
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Country | US
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Telephone | 202-820-6698
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Fax |
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | STRAFFORD ACHANYI NGOSONG
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Credential |
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Telephone | 202-820-6698
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number |
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License Number State |
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