=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306116215
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARIEN N HALEY CEO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2012
-----------------------------------------------------
Last Update Date | 01/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 424 MARKET ST SUITE 101
-----------------------------------------------------
City | SUFFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23434-5200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-934-1400
-----------------------------------------------------
Fax | 757-934-1404
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 424 MARKET ST SUITE 101
-----------------------------------------------------
City | SUFFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23434-5200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-934-1400
-----------------------------------------------------
Fax | 757-934-1404
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | HCO-12774
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------