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General NPI Number Information
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NPI Number | 1407939655
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Entity Type | Organization
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Legal Business Name | OLA HOME FOR BOYS, LLC
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Dates
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Enumeration Date | 10/23/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1802 N 22ND ST
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City | RICHMOND
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State | VA
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Zip | 23223-4434
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Country | US
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Telephone | 804-343-5153
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Fax | 804-343-5153
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Provider Business Mailing Address
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Address Line | PO BOX 2074
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City | MECHANICSVILLE
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State | VA
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Zip | 23116-0010
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Country | US
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Telephone | 804-343-5153
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Fax | 804-343-5153
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Authorized Official
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Title or Position | CHIEF ADMINISTRATIVE OFFICER
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Name | MR. KEITH RODNEY BROOKS
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Credential |
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Telephone | 804-343-5153
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 | 0021836400
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License Number State | VA
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