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General NPI Number Information
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NPI Number | 1427400050
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Entity Type | Organization
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Legal Business Name | COMPASSIONATE CARE GROUP HOMES, LLC
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Dates
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Enumeration Date | 07/07/2016
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Last Update Date | 07/07/2016
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Provider Practice Location Address
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Address Line | 4413 SAN CARLOS DR
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City | FAIRFAX
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State | VA
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Zip | 22030-5372
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Country | US
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Telephone | 240-604-4921
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Fax |
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Provider Business Mailing Address
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Address Line | 4413 SAN CARLOS DR
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City | FAIRFAX
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State | VA
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Zip | 22030-5372
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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 | PROGRAM DIRECTOR
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Name | GEORGETTE DEYONOU
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Credential |
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Telephone | 240-604-4921
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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 | 2539-01-001
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License Number State | VA
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