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General NPI Number Information
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NPI Number | 1528347358
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Entity Type | Organization
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Legal Business Name | MYSTIC MEADOW GROUP HOME, LLC
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Dates
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Enumeration Date | 08/10/2011
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Last Update Date | 08/10/2011
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Provider Practice Location Address
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Address Line | 2157 CAMPBELL AVE
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City | LYNCHBURG
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State | VA
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Zip | 24501-6405
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Country | US
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Telephone | 434-847-2001
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Fax | 434-847-2022
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Provider Business Mailing Address
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Address Line | 2157 CAMPBELL AVE
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City | LYNCHBURG
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State | VA
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Zip | 24501-6405
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Country | US
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Telephone | 434-847-2001
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Fax | 434-847-2022
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Authorized Official
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Title or Position | PRESIDENT
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Name | MRS. VALERIE A ELLIOTT
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Credential |
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Telephone | 434-847-2001
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number |
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License Number State | VA
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