=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598963548
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CEE-BREEZE PERSONAL CARE SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2007
-----------------------------------------------------
Last Update Date | 08/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 410 ELM AVE SW
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24016-3920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-343-2200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1140
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23851-1140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-338-7747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MR. CLARENCE R BAKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-338-7747
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | 94703001
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | 94002029
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------