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General NPI Number Information
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NPI Number | 1871099721
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Entity Type | Organization
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Legal Business Name | IMAGINATION LLC
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Dates
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Enumeration Date | 03/31/2018
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Last Update Date | 03/31/2018
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Provider Practice Location Address
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Address Line | 318 N WILKINSON RD
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City | RICHMOND
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State | VA
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Zip | 23227-1631
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Country | US
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Telephone | 804-716-0593
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Fax | 804-330-6698
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Provider Business Mailing Address
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Address Line | PO BOX 28586
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City | HENRICO
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State | VA
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Zip | 23228-8586
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Country | US
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Telephone | 804-716-0593
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Fax | 804-330-6698
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Authorized Official
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Title or Position | CHIEF ADMINISTRATIVE OFFICER
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Name | MS. MONICA BOLTON
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Credential |
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Telephone | 804-402-1356
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | 3189-14-008
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License Number State | VA
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