=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679939169
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | T'LAB, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2016
-----------------------------------------------------
Last Update Date | 01/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 823 S JONES ST
-----------------------------------------------------
City | PETERSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23803-4952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-590-2227
-----------------------------------------------------
Fax | 804-451-9573
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3734 W AUTUMN DR
-----------------------------------------------------
City | NORTH DINWIDDIE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23803-8433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-721-6861
-----------------------------------------------------
Fax | 804-451-9573
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | JANINE JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-721-6861
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | 38214035
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------