=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982677027
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HALO, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1857A FORT MAHONE ST
-----------------------------------------------------
City | PETERSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23805-2761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-733-9140
-----------------------------------------------------
Fax | 804-733-9216
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1857A FORT MAHONE ST P. O. BOX 28
-----------------------------------------------------
City | PETERSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23805-2761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-733-9140
-----------------------------------------------------
Fax | 804-733-9216
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. HARRY LEGROS
-----------------------------------------------------
Credential | QMRP/QMHP
-----------------------------------------------------
Telephone | 804-733-9140
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | 523-01
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------