MEDICARE: LIFE ENRICHMENT CENTER OF VIRGINIA

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	1041C0700X	Clinical Social Worker	0904006615	VA

General Provider Information

NPI Number	:	1063833606
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE ENRICHMENT CENTER OF VIRGINIA

Provider Business Mailing Address
First Line	:	9409 HULL STREET RD STE D1
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23236-1200
Country	:	US
Telephone Number	:	804-745-2225
Fax Number	:	804-745-2242

Provider Business Practice Location Address
First Line	:	9409 HULL STREET RD STE D1
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23236-1200
Country	:	US
Telephone Number	:	804-745-2225
Fax Number	:	804-745-2242

Authorized Official
Title or Position	:	OWNER
Name	:	BRITNEY CHACEY
Credential	:	LCSW
Telephone Number	:	804-745-2225

Provider Enumeration Date	:	12/28/2013
Last Update Date	:	12/28/2013

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