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General NPI Number Information
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NPI Number | 1447041504
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Entity Type | Organization
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Legal Business Name | VIDAL CARE RESIDENCY LLC
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Dates
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Enumeration Date | 05/16/2025
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Last Update Date | 05/16/2025
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Provider Practice Location Address
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Address Line | 109 CROCKER ST
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City | SUFFOLK
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State | VA
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Zip | 23434-2605
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Country | US
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Telephone | 757-809-0301
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Fax |
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Provider Business Mailing Address
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Address Line | 126 BOWRIDER DR
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City | SUFFOLK
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State | VA
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Zip | 23435-4117
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Country | US
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Telephone | 757-609-1534
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Fax |
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Authorized Official
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Title or Position | CO-OWNER
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Name | LEARY WILLIAMS
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Credential |
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Telephone | 757-609-1534
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number |
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License Number State |
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