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General NPI Number Information
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NPI Number | 1275072993
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Entity Type | Organization
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Legal Business Name | CALVIN JAYNE QUALITY LIVING, LLC
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Dates
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Enumeration Date | 02/14/2017
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Last Update Date | 02/14/2017
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Provider Practice Location Address
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Address Line | 6688 TATUM RD
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City | DISPUTANTA
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State | VA
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Zip | 23842-6902
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Country | US
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Telephone | 804-550-8674
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Fax | 804-251-1299
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Provider Business Mailing Address
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Address Line | 6688 TATUM RD
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City | DISPUTANTA
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State | VA
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Zip | 23842-6902
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Country | US
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Telephone | 804-550-8674
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Fax | 804-251-1299
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MRS. JENNIFER JAYNE WHITE
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Credential |
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Telephone | 804-550-8674
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 | 2182-01-002
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License Number State | VA
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