MEDICARE: PRYOR HOUSE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	426-01-001	VA

General Provider Information

NPI Number	:	1013139690
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRYOR HOUSE, INC.

Provider Business Mailing Address
First Line	:	1822 BOGESE DR
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23805-2920
Country	:	US
Telephone Number	:	804-733-4395
Fax Number	:

Provider Business Practice Location Address
First Line	:	1822 BOGESE DR
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23805-2920
Country	:	US
Telephone Number	:	804-733-4395
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. JOYCE T BROWN
Credential	:
Telephone Number	:	804-732-2060

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	08/22/2020

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