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General NPI Number Information
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NPI Number | 1114353463
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Entity Type | Organization
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Legal Business Name | OVERCOMERS RESIDENTIAL SERVICES, LLC
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Dates
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Enumeration Date | 09/18/2013
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Last Update Date | 09/18/2013
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Provider Practice Location Address
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Address Line | 2519 PROFESSIONAL RD SUITE A
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23235-3200
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Country | US
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Telephone | 804-562-7874
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Fax | 804-482-2947
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Provider Business Mailing Address
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Address Line | PO BOX 661
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City | CHESTERFIELD
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State | VA
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Zip | 23832-0009
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Country | US
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Telephone | 804-562-7874
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Fax | 804-482-2947
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Authorized Official
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Title or Position | OWNER
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Name | MR. MARCEL DARRYL HIGGINS
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Credential |
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Telephone | 804-562-7874
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | 1569
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License Number State | VA
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