=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174348379
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CIVITAS PARA VITA LIMITED LIABILITY CO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2024
-----------------------------------------------------
Last Update Date | 04/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 875 IRON BRIDGE RD
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23868-3937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-917-1211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 875 IRON BRIDGE RD
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23868-3937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-917-1211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JESSICA SIOTIA BEATRICE HURDLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 434-917-1211
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------