=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972675908
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY RESIDENCES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2006
-----------------------------------------------------
Last Update Date | 01/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 807 NORTH JACKSON STREET CRI JACKSON STREET ICF
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-842-2333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14160 NEWBROOK DR
-----------------------------------------------------
City | CHANTILLY
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20151-2297
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-842-2333
-----------------------------------------------------
Fax | 703-842-2311
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF ADMINISTRATION/CFO
-----------------------------------------------------
Name | TERRY WILLIAM HURLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 703-842-2321
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 315P00000X
-----------------------------------------------------
Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
-----------------------------------------------------
License Number | 05801001
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------