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General NPI Number Information
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NPI Number | 1497070296
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Entity Type | Organization
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Legal Business Name | INFINITE POTENTIAL SUPPORTIVE SERVICES, LLC
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Dates
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Enumeration Date | 04/05/2010
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Last Update Date | 04/05/2010
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Provider Practice Location Address
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Address Line | 2114 AVON STREET
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City | EAST STONE GAP
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State | VA
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Zip | 24246
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Country | US
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Telephone | 276-523-2797
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Fax | 276-523-2797
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Provider Business Mailing Address
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Address Line | PO BOX 390 2114 AVON STREET
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City | EAST STONE GAP
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State | VA
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Zip | 24246-0390
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Country | US
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Telephone | 276-523-2797
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Fax | 276-523-2797
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Authorized Official
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Title or Position | DIRECTER/OWNER
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Name | MRS. HEATHER L MURPHY
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Credential |
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Telephone | 276-523-2797
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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 | 1213
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License Number State | VA
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