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General NPI Number Information
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NPI Number | 1356825301
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Entity Type | Organization
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Legal Business Name | COMMONWEALTH RESIDENTIAL LIVING LLC
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Dates
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Enumeration Date | 09/16/2018
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Last Update Date | 09/16/2018
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Provider Practice Location Address
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Address Line | 232 TARABY DR
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City | SANDSTON
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State | VA
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Zip | 23150-2148
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Country | US
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Telephone | 804-921-4237
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Fax |
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Provider Business Mailing Address
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Address Line | 232 TARABY DR
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City | SANDSTON
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State | VA
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Zip | 23150-2148
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | CRYSTAL WHITE
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Credential |
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Telephone | 804-253-5529
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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