MEDICARE: SKYE IS THE LIMIT RESIDENTIAL SERVICES

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	1781	VA

General Provider Information

NPI Number	:	1033493200
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SKYE IS THE LIMIT RESIDENTIAL SERVICES

Provider Business Mailing Address
First Line	:	9916 REYMET CT
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23237-2375
Country	:	US
Telephone Number	:	804-271-0825
Fax Number	:

Provider Business Practice Location Address
First Line	:	9916 REYMET CT
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23237-2375
Country	:	US
Telephone Number	:	804-271-0825
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. ANTYWONE WILSON
Credential	:
Telephone Number	:	443-591-1166

Provider Enumeration Date	:	10/05/2011
Last Update Date	:	10/05/2011

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