=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144455064
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENDEPENDENCE CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2009
-----------------------------------------------------
Last Update Date | 05/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6300 E VIRGINIA BEACH BLVD
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23502-2827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-461-8007
-----------------------------------------------------
Fax | 757-461-5375
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6300 E VIRGINIA BEACH BLVD
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23502-2827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-461-8007
-----------------------------------------------------
Fax | 757-461-5375
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF ADVOCACY AND SERVICES
-----------------------------------------------------
Name | MAUREEN HOLLOWELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-351-1584
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------