=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215455241
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEIGHBORLY RESIDENTIAL CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2017
-----------------------------------------------------
Last Update Date | 06/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2404 NORTHUMBERLAND AVE
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23220-1525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-709-1736
-----------------------------------------------------
Fax | 804-709-1788
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4135 HOLCOMBE RD
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23234-3033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-743-8618
-----------------------------------------------------
Fax | 804-709-1788
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. STANLEY FREEMAN
-----------------------------------------------------
Credential | CERTIFIED AIDE
-----------------------------------------------------
Telephone | 804-709-1736
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------