=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346025368
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POTTER'S GROUP HOME LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2023
-----------------------------------------------------
Last Update Date | 08/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3641 DAHLGREN PLACE
-----------------------------------------------------
City | DUMFRIES
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22026-2602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-477-8172
-----------------------------------------------------
Fax | 703-221-9746
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3641 DAHLGREN PLACE
-----------------------------------------------------
City | DUMFRIES
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22026-2602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-477-8172
-----------------------------------------------------
Fax | 703-221-9746
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PROGRAM DIRECTOR
-----------------------------------------------------
Name | ABA ADUSEI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 571-477-8172
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------