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General NPI Number Information
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NPI Number | 1316665466
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Entity Type | Organization
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Legal Business Name | THE VIRGINIA HOUSE, LLC
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Dates
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Enumeration Date | 08/16/2022
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Last Update Date | 01/25/2024
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Provider Practice Location Address
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Address Line | 344 BOULEVARD ST
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City | SHREVEPORT
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State | LA
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Zip | 71104-2422
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Country | US
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Telephone | 318-820-6941
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Fax |
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Provider Business Mailing Address
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Address Line | 344 BOULEVARD ST
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City | SHREVEPORT
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State | LA
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Zip | 71104-2422
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Country | US
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Telephone | 318-820-6941
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CLEVELAND MOUTON III
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Credential |
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Telephone | 318-820-6941
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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