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General NPI Number Information
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NPI Number | 1568702256
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Entity Type | Organization
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Legal Business Name | GRAND ANNE RESIDENCES, LLC
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Dates
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Enumeration Date | 02/18/2013
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Last Update Date | 02/18/2013
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Provider Practice Location Address
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Address Line | 2104 WALNUT AVE
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City | BUENA VISTA
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State | VA
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Zip | 24416-2738
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Country | US
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Telephone | 540-261-2222
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Fax | 540-261-2222
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Provider Business Mailing Address
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Address Line | 2104 WALNUT AVE
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City | BUENA VISTA
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State | VA
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Zip | 24416-2738
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Country | US
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Telephone | 540-261-2222
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Fax | 540-261-2222
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MS. DEBORAH Z SHAFER
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Credential | QRMP
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Telephone | 540-261-2222
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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 | 1952
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License Number State | VA
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