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General NPI Number Information
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NPI Number | 1700639770
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Entity Type | Organization
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Legal Business Name | IMAGO DEI SUPPORT SERVICES. LLC
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Dates
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Enumeration Date | 04/09/2024
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Last Update Date | 04/09/2024
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Provider Practice Location Address
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Address Line | 12531 CLIPPER DR STE 101
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City | WOODBRIDGE
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State | VA
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Zip | 22192-2355
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Country | US
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Telephone | 571-427-2710
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Fax | 804-714-0023
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Provider Business Mailing Address
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Address Line | 12531 CLIPPER DR STE 101
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City | WOODBRIDGE
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State | VA
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Zip | 22192-2355
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Country | US
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Telephone | 804-218-2595
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Fax | 804-714-0023
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | MS. VICTORIA A GBADEBO
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Credential | REGISTERED NURSE
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Telephone | 804-218-2595
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number |
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License Number State |
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