=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710234240
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW LIFE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2012
-----------------------------------------------------
Last Update Date | 08/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11030 WARWICK BLVD BLDG B
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23601-3250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-595-3890
-----------------------------------------------------
Fax | 757-595-3891
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11030 WARWICK BLVD BLDG B
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23601-3250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-595-3890
-----------------------------------------------------
Fax | 757-595-3891
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CAO
-----------------------------------------------------
Name | MR. RICHARD E ROMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-595-3890
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 1729
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------