=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285335703
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE COMFORT PLACE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2023
-----------------------------------------------------
Last Update Date | 03/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3817 GREENWOOD DR
-----------------------------------------------------
City | SOUTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23803-1911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-490-3502
-----------------------------------------------------
Fax | 804-898-3405
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3817 GREENWOOD DR
-----------------------------------------------------
City | SOUTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23803-1911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-490-3502
-----------------------------------------------------
Fax | 804-898-3405
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ADENIKE OLUWAKEMI OKEGBENRO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-490-3502
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------