=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992020176
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIRGINIA MENNONITE HOME, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2010
-----------------------------------------------------
Last Update Date | 03/31/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1401 VIRGINIA AVE
-----------------------------------------------------
City | HARRISONBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22802-2433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-564-3550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1501 VIRGINIA AVE
-----------------------------------------------------
City | HARRISONBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22802-2452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MR. CURTIS STUTZMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 540-564-3414
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | VLO-000272
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------