=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962734855
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOURNEYS CROSSING ASSISTED LIVING FACILITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2010
-----------------------------------------------------
Last Update Date | 02/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 N STUART AVE
-----------------------------------------------------
City | ELKTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22827-1451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-298-0054
-----------------------------------------------------
Fax | 540-298-7049
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 N STUART AVE
-----------------------------------------------------
City | ELKTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22827-1451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-298-0054
-----------------------------------------------------
Fax | 540-298-7049
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LPN/ LICENSED ADMINISTRATOR
-----------------------------------------------------
Name | MRS. THERESA LYNN DEMASTUS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 540-298-0054
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------