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General NPI Number Information
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NPI Number | 1144699034
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Entity Type | Organization
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Legal Business Name | GROUP RESIDENTIAL AND CARE ESTABLISHMENT
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Dates
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Enumeration Date | 09/21/2015
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Last Update Date | 09/21/2015
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Provider Practice Location Address
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Address Line | 2021B CUNNINGHAM DR SUITE 3
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City | HAMPTON
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State | VA
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Zip | 23666-3326
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Country | US
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Telephone | 757-325-8399
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Fax | 757-325-8321
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Provider Business Mailing Address
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Address Line | PO BOX 8227
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City | HAMPTON
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State | VA
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Zip | 23666-0280
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Country | US
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Telephone | 757-325-8399
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Fax | 757-325-8321
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. RODNEY JEROME HAWKINS
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Credential |
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Telephone | 757-325-8399
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number | 71303011
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | 71301001
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License Number State | VA
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