=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952601866
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WCCB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2010
-----------------------------------------------------
Last Update Date | 10/26/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3100 SHORE DRIVE
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23451-9864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-842-2437
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1421 BRADEN CRES
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23502-2108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-842-2437
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LPTA
-----------------------------------------------------
Name | MRS. CRYSTAL M LARIOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-842-2437
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 2306602413
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------