=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326462334
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNER-VISION EDUCATION CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2014
-----------------------------------------------------
Last Update Date | 02/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1572 STANDING RIDGE DR
-----------------------------------------------------
City | POWHATAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23139-8051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-794-1573
-----------------------------------------------------
Fax | 804-414-7026
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1572 STANDING RIDGE DR
-----------------------------------------------------
City | POWHATAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23139-8051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-794-1573
-----------------------------------------------------
Fax | 804-414-7026
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAMON PETERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-794-1573
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | 199102006
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------