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General NPI Number Information
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NPI Number | 1205166964
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Entity Type | Organization
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Legal Business Name | MYSTIC MEADOWS HOME CARE SERVICES LLC
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Dates
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Enumeration Date | 12/31/2009
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Last Update Date | 12/31/2009
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Provider Practice Location Address
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Address Line | 6142 PLEASANT VALLEY RD
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City | LYNCHBURG
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State | VA
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Zip | 24504-4538
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Country | US
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Telephone | 434-845-3318
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Fax |
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Provider Business Mailing Address
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Address Line | 6142 PLEASANT VALLEY RD
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City | LYNCHBURG
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State | VA
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Zip | 24504-4538
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | GENERAL MANAGER
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Name | MR. WAYNE ANDERSON ELLIOTT
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Credential |
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Telephone | 434-845-0709
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 385H00000X
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Taxonomy Name | Respite Care
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License Number | HCO09548
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number | HCO09548
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License Number State | VA
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