MEDICARE: ACHIEVABLE DEVELOPMENT SERVICES, LLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)		VA

General Provider Information

NPI Number	:	1063936979
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACHIEVABLE DEVELOPMENT SERVICES, LLC

Provider Business Mailing Address
First Line	:	1124 S WEDGEMONT DR
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23236-4811
Country	:	US
Telephone Number	:	804-833-6399
Fax Number	:	804-464-4529

Provider Business Practice Location Address
First Line	:	1124 S WEDGEMONT DR
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23236-4811
Country	:	US
Telephone Number	:	804-833-6399
Fax Number	:	804-464-4529

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. MARQUISE LONNELL ROSE
Credential	:
Telephone Number	:	804-833-6399

Provider Enumeration Date	:	08/01/2017
Last Update Date	:	08/01/2017

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